Provider Demographics
NPI:1053334656
Name:ZYGMUNT, JACK
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:ZYGMUNT
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 1:626 TRAIL AVE
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-4934
Mailing Address - Country:US
Mailing Address - Phone:301-662-1997
Mailing Address - Fax:301-668-2202
Practice Address - Street 1:626 TRAIL AVE
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-4934
Practice Address - Country:US
Practice Address - Phone:301-662-1997
Practice Address - Fax:301-668-2202
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD17841225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKBC4HO-64125101OtherBC/BS
MDS404-0014OtherCAREFIRST
DCG00930-014486H30Medicare PIN
MDKBC4HO-64125101OtherBC/BS