Provider Demographics
NPI:1275621807
Name:ZAK, MATT (MD)
Entity Type:Individual
Prefix:DR
First Name:MATT
Middle Name:
Last Name:ZAK
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 1:1401 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-2407
Mailing Address - Country:US
Mailing Address - Phone:218-728-4491
Mailing Address - Fax:218-728-4404
Practice Address - Street 1:3860 MONROE RD
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-8399
Practice Address - Country:US
Practice Address - Phone:920-496-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN501912084P0800X
IL036-1130092084P0800X
WI46164-0202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1275621807Medicaid
WI1575621807Medicaid
MN1275621807Medicaid