Provider Demographics
NPI:1093710626
Name:ZACKS, JASON ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:ALAN
Last Name:ZACKS
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 1:1920 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-3008
Mailing Address - Country:US
Mailing Address - Phone:334-678-1400
Mailing Address - Fax:334-678-1432
Practice Address - Street 1:1920 FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-3008
Practice Address - Country:US
Practice Address - Phone:334-678-1400
Practice Address - Fax:334-678-1432
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL24494207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
51506924Medicare ID - Type Unspecified
K711Medicare PIN
G64013Medicare UPIN