Provider Demographics
NPI:1134131931
Name:ZUCKMAN, MICHAEL ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ROBERT
Last Name:ZUCKMAN
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 1:823 WEST ST
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:NY
Mailing Address - Zip Code:10528-1216
Mailing Address - Country:US
Mailing Address - Phone:718-361-5261
Mailing Address - Fax:718-361-5266
Practice Address - Street 1:4103 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11104-2801
Practice Address - Country:US
Practice Address - Phone:718-361-5261
Practice Address - Fax:718-361-5266
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174617207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01167986Medicaid
NYF22921Medicare UPIN
NY01167986Medicaid