Provider Demographics
NPI:1346388691
Name:ZACHAREWICZ, MARK HALL (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:HALL
Last Name:ZACHAREWICZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2523 BROADWAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-4240
Mailing Address - Country:US
Mailing Address - Phone:303-938-9244
Mailing Address - Fax:303-413-1308
Practice Address - Street 1:2523 BROADWAY
Practice Address - Street 2:SUITE 200
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-4240
Practice Address - Country:US
Practice Address - Phone:303-938-9244
Practice Address - Fax:303-413-1308
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2216174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC802772Medicare PIN