Provider Demographics
NPI:1619714508
Name:MIRANDA ZAZUETA, GODOLFINO (MD)
Entity type:Individual
Prefix:
First Name:GODOLFINO
Middle Name:
Last Name:MIRANDA ZAZUETA
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:SAMAHIL 138
Mailing Address - Street 2:SAMAHIL 136
Mailing Address - City:MEXICO CITY
Mailing Address - State:CIUDAD DE MEXICO
Mailing Address - Zip Code:14200
Mailing Address - Country:MX
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1250 E MARSHALL ST FL 14
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-5023
Practice Address - Country:US
Practice Address - Phone:804-616-9080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-09
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0109542121207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology