Provider Demographics
NPI:1275586075
Name:ZASTROW, MICHAEL LAWRENCE (DC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LAWRENCE
Last Name:ZASTROW
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 S 32ND AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-3958
Mailing Address - Country:US
Mailing Address - Phone:715-848-2526
Mailing Address - Fax:715-848-2225
Practice Address - Street 1:2920 S WEBSTER AVE
Practice Address - Street 2:SUITE B
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-1594
Practice Address - Country:US
Practice Address - Phone:920-339-9774
Practice Address - Fax:920-339-9764
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1813-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38998500OtherMEDICAID CLINIC NUMBER
WI38777600Medicaid
T63738Medicare UPIN