Healthcare Provider Details

I. General information

NPI: 1225024763
Provider Name (Legal Business Name): JOSE T ZAGLUL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 01/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

379 6TH AVE W
BRADENTON FL
34205-8820
US

IV. Provider business mailing address

379 6TH AVE W
BRADENTON FL
34205-8820
US

V. Phone/Fax

Practice location:
  • Phone: 941-782-4259
  • Fax: 941-782-4101
Mailing address:
  • Phone: 941-782-4259
  • Fax: 941-782-4101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberME60726
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME60726
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: