Healthcare Provider Details

I. General information

NPI: 1609090158
Provider Name (Legal Business Name): MARCELLO A BORZATTA MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 05/24/2024
Certification Date: 05/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 BROOKMEADE DR
CRESTVIEW FL
32539-7304
US

IV. Provider business mailing address

2260 S FERDON BLVD
CRESTVIEW FL
32536-8457
US

V. Phone/Fax

Practice location:
  • Phone: 850-305-2105
  • Fax: 239-663-3061
Mailing address:
  • Phone: 850-305-2105
  • Fax: 239-663-3061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MARCELLO A BORZATTA
Title or Position: PRESIDENT
Credential: MD
Phone: 850-849-1642