Healthcare Provider Details

I. General information

NPI: 1376582908
Provider Name (Legal Business Name): M. JERRY ZAPANTA MARIANO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: M. JERRY Z MARIANO M.D.

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1542 GOLF COURSE RD SUITE 201
GRAND RAPIDS MN
55744-9603
US

IV. Provider business mailing address

1542 GOLF COURSE RD SUITE 201
GRAND RAPIDS MN
55744-9603
US

V. Phone/Fax

Practice location:
  • Phone: 218-326-3433
  • Fax: 218-326-3435
Mailing address:
  • Phone: 218-326-3433
  • Fax: 218-326-3435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number43720
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License Number43720
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: