Healthcare Provider Details

I. General information

NPI: 1134234040
Provider Name (Legal Business Name): ROSA ZIDELIS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 N ORANGE ST
NEW SMYRNA BEACH FL
32168-6733
US

IV. Provider business mailing address

311 N ORANGE ST
NEW SMYRNA BEACH FL
32168-6733
US

V. Phone/Fax

Practice location:
  • Phone: 386-416-1023
  • Fax: 386-416-1037
Mailing address:
  • Phone: 386-416-1023
  • Fax: 386-416-1037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME 15540
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: