Provider Demographics
NPI:1578098166
Name:ZAMORA, MARIO PHILLIP (MD)
Entity type:Individual
Prefix:DR
First Name:MARIO
Middle Name:PHILLIP
Last Name:ZAMORA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17189 INTERSTATE 45 S
Mailing Address - Street 2:SUITE 675
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77385-3320
Mailing Address - Country:US
Mailing Address - Phone:936-270-3900
Mailing Address - Fax:936-271-1584
Practice Address - Street 1:17201 INTERSTATE 45 S
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77385-3311
Practice Address - Country:US
Practice Address - Phone:936-270-3900
Practice Address - Fax:936-271-1584
Is Sole Proprietor?:No
Enumeration Date:2017-04-21
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25IA124086002084N0400X
TXV17172084V0102X
TN638662084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS200007030Medicaid
TNQ067438Medicaid