Healthcare Provider Details

I. General information

NPI: 1578829156
Provider Name (Legal Business Name): CARLY SUZANNE ZAPATA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARLY SUZANNE BENNER MD

II. Dates (important events)

Enumeration Date: 04/08/2012
Last Update Date: 02/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 11TH AVE APT 6
SAN FRANCISCO CA
94122-2256
US

IV. Provider business mailing address

1215 11TH AVE APT 6
SAN FRANCISCO CA
94122-2256
US

V. Phone/Fax

Practice location:
  • Phone: 209-406-5942
  • Fax:
Mailing address:
  • Phone: 209-406-5942
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License NumberA127573
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: