Provider Demographics
NPI:1114904505
Name:ZACKS, JEROME SAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:SAUL
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 1:1120 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-1242
Mailing Address - Country:US
Mailing Address - Phone:212-289-8400
Mailing Address - Fax:212-876-6307
Practice Address - Street 1:1120 PARK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-1242
Practice Address - Country:US
Practice Address - Phone:212-289-8400
Practice Address - Fax:212-876-6307
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-27
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY109597207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00194523Medicaid
NY00194523Medicaid
NY00194523Medicaid
NYB17189Medicare UPIN