Provider Demographics
NPI:1518189927
Name:LISA D ZACK MD PA
Entity Type:Organization
Organization Name:LISA D ZACK MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:MS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-263-1717
Mailing Address - Street 1:801 ANCHOR RODE DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34103-2742
Mailing Address - Country:US
Mailing Address - Phone:239-263-1717
Mailing Address - Fax:239-403-9410
Practice Address - Street 1:801 ANCHOR RODE DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34103-2742
Practice Address - Country:US
Practice Address - Phone:239-263-1717
Practice Address - Fax:239-403-9410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL21478Medicare PIN