1366406357 NPI number — DR. MARK G ZUKAITIS M.D.

Table of content: DR. MARK G ZUKAITIS M.D. (NPI 1366406357)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366406357 NPI number — DR. MARK G ZUKAITIS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ZUKAITIS
Provider First Name:
MARK
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366406357
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/31/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5615
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRESNO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93755-5615
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-436-1000
Provider Business Mailing Address Fax Number:
559-354-4235

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2825 RANDOLPH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28211-1075
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-377-1647
Provider Business Practice Location Address Fax Number:
704-358-8267
Provider Enumeration Date:
04/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  20225 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207LP2900X , with the licence number: 20225 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1146V . This is a "BLUE CROSS NC ID#" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 891146V , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: N20225 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com