Provider Demographics
NPI:1003459975
Name:BEVILACQUA, ZACHARY
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:
Last Name:BEVILACQUA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ZACHARY
Other - Middle Name:
Other - Last Name:BEVILACQUA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ATC
Mailing Address - Street 1:123 MEDALLION CIR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-3242
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:123 MEDALLION CIR
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-3242
Practice Address - Country:US
Practice Address - Phone:585-313-4608
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-23
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002336204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine