Provider Demographics
NPI:1558325969
Name:ZISCHKAU, DOUGLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:
Last Name:ZISCHKAU
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 1:5055 MCNUTT RD
Mailing Address - Street 2:
Mailing Address - City:SANTA TERESA
Mailing Address - State:NM
Mailing Address - Zip Code:88008-9442
Mailing Address - Country:US
Mailing Address - Phone:575-589-5005
Mailing Address - Fax:575-589-1333
Practice Address - Street 1:5055 MCNUTT RD
Practice Address - Street 2:
Practice Address - City:SANTA TERESA
Practice Address - State:NM
Practice Address - Zip Code:88008-9442
Practice Address - Country:US
Practice Address - Phone:575-589-5005
Practice Address - Fax:575-589-1333
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM92381207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM396826ZS5HOtherWELLMED PTAN
NM14645Medicaid
NM396826ZS5HOtherWELLMED PTAN