Basic Information
| Provider Information | |||||||||
| NPI: | 1679641708 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ZENDEHROUH | ||||||||
| FirstName: | PEDRAM | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5220 BELFORT RD | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322566017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044463451 | ||||||||
| FaxNumber: | 9044463013 | ||||||||
| Practice Location | |||||||||
| Address1: | 951 N WASHINGTON AVE | ||||||||
| Address2: | PARRISH WOUND HEALING CENTER | ||||||||
| City: | TITUSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327962163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3212686795 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 01/26/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 2004016404 | MO | Y | Allopathic & Osteopathic Physicians | Surgery | 2086S0127X | 2004016404 | MO | N | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery |
ID Information
| ID | Type | State | Issuer | Description | 431560263006 | 01 | MO | TRICARE | OTHER | P00195701 | 01 | MO | RAILROAD MEDICARE | OTHER | 209022003 | 05 | MO | MEDICAID |