Provider Demographics
NPI:1407964695
Name:ZACK, JUSTIN (MD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:ZACK
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 1:1333 ROANOKE AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901
Mailing Address - Country:US
Mailing Address - Phone:631-727-2755
Mailing Address - Fax:631-208-9521
Practice Address - Street 1:1333 ROANOKE AVE
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901
Practice Address - Country:US
Practice Address - Phone:631-727-2755
Practice Address - Fax:631-208-9521
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2094652085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02206999Medicaid
NYCF3402OtherRR MEDICARE
NYW11401OtherBC/BS
NYW22111OtherMEDICARE GROUP SHR
NYWEU091OtherMEDICARE GROUP HR
NYW22111OtherMEDICARE GROUP SHR
H42722Medicare UPIN