Provider Demographics
NPI:1306854203
Name:ZACKARIYA, KHALEELUR R SR (MD)
Entity Type:Individual
Prefix:DR
First Name:KHALEELUR
Middle Name:R
Last Name:ZACKARIYA
Suffix:SR
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 1:810 PARK PL
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-3520
Mailing Address - Country:US
Mailing Address - Phone:574-472-6901
Mailing Address - Fax:574-472-6262
Practice Address - Street 1:5215 HOLYCROSS PARKWAY
Practice Address - Street 2:
Practice Address - City:MISHIWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545
Practice Address - Country:US
Practice Address - Phone:574-237-7168
Practice Address - Fax:574-472-6262
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036098582207R00000X
IN01066056A207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200930470Medicaid
547960Medicare ID - Type Unspecified
IN941050EEEEMedicare PIN
IN200930470Medicaid