Healthcare Provider Details

I. General information

NPI: 1053863985
Provider Name (Legal Business Name): HISHAM ZIYOUT L.A.T., A.T.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2016
Last Update Date: 10/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 N CHARLES ST
BALTIMORE MD
21218-2608
US

IV. Provider business mailing address

1003 SAYWARD AVENUE
BALTIMORE MD
21234
US

V. Phone/Fax

Practice location:
  • Phone: 410-516-8458
  • Fax:
Mailing address:
  • Phone: 410-905-4374
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberA0000746
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: