Provider Demographics
NPI:1033408968
Name:SHANITKVICH, ZACHARY ALAN
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:ALAN
Last Name:SHANITKVICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1721 EBENEZER RD STE 145
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-1119
Mailing Address - Country:US
Mailing Address - Phone:803-328-2401
Mailing Address - Fax:
Practice Address - Street 1:1721 EBENEZER RD STE 145
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1119
Practice Address - Country:US
Practice Address - Phone:803-328-2401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-31
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018015705207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNCQ953AMedicare PIN