Provider Demographics
NPI:1568431559
Name:ZACK, PERRY EARL (DO)
Entity Type:Individual
Prefix:
First Name:PERRY
Middle Name:EARL
Last Name:ZACK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:751 E 81ST AVE
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-5538
Mailing Address - Country:US
Mailing Address - Phone:219-791-9476
Mailing Address - Fax:219-791-9542
Practice Address - Street 1:751 E 81ST AVE
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-5538
Practice Address - Country:US
Practice Address - Phone:219-791-9476
Practice Address - Fax:219-791-9542
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001537207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200079230BMedicaid
IN00000093814OtherBLUE CROSS BLUE SHIELD
IN00000093814OtherBLUE CROSS BLUE SHIELD
IN148290Medicare ID - Type Unspecified