Provider Demographics
NPI:1225279425
Name:ZACCARO, RICHARD C (PT, DPT)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:C
Last Name:ZACCARO
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1609 N STRONG BLVD
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501-3839
Mailing Address - Country:US
Mailing Address - Phone:918-426-1322
Mailing Address - Fax:918-426-1323
Practice Address - Street 1:2234 W HOUSTON ST STE B
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-3519
Practice Address - Country:US
Practice Address - Phone:918-259-1888
Practice Address - Fax:918-251-3725
Is Sole Proprietor?:No
Enumeration Date:2009-03-18
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4427225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200330730AMedicaid
OK200330730AMedicaid