Provider Demographics
NPI:1275510950
Name:ZABAK, DARICE L (MD)
Entity Type:Individual
Prefix:DR
First Name:DARICE
Middle Name:L
Last Name:ZABAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9250 SW HALL BLVD
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-6721
Mailing Address - Country:US
Mailing Address - Phone:503-293-0161
Mailing Address - Fax:
Practice Address - Street 1:9250 SW HALL BLVD
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-6721
Practice Address - Country:US
Practice Address - Phone:503-293-0161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036109954207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036109954OtherSTATE LICENSE
IL036109954Medicaid
IL036109954OtherSTATE LICENSE
ILK15623Medicare PIN
ILA16284Medicare UPIN
ILK14837Medicare ID - Type UnspecifiedPROVIDER ID# FHC
ILK14838Medicare ID - Type UnspecifiedPROVIDER ID# MTM
ILK14839Medicare ID - Type UnspecifiedPROVIDER ID# ROC