Provider Demographics
NPI:1326408303
Name:ZACHARY, DEWAYNE THOMAS JR
Entity Type:Individual
Prefix:
First Name:DEWAYNE
Middle Name:THOMAS
Last Name:ZACHARY
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 W FREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204
Mailing Address - Country:US
Mailing Address - Phone:209-888-4519
Mailing Address - Fax:
Practice Address - Street 1:6508 DANNY DR UNIT 227
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-5352
Practice Address - Country:US
Practice Address - Phone:209-888-4519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator