Provider Demographics
NPI:1548280100
Name:ZOTTA, JEFFREY JOHN (RPAC)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:JOHN
Last Name:ZOTTA
Suffix:
Gender:M
Credentials:RPAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1393
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12134-1393
Mailing Address - Country:US
Mailing Address - Phone:518-863-2749
Mailing Address - Fax:
Practice Address - Street 1:2184 S SHORE RD
Practice Address - Street 2:
Practice Address - City:HADLEY
Practice Address - State:NY
Practice Address - Zip Code:12835-3601
Practice Address - Country:US
Practice Address - Phone:518-863-2749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004930363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01563964Medicaid
NY000405762001OtherBLUE SHIELD NENY
NY000405762001OtherBLUE SHIELD NENY
NYP00162957Medicare PIN
NYA53565Medicare UPIN
NY56438CMedicare ID - Type Unspecified