Provider Demographics
NPI:1639126592
Name:ZACKARIYA, KHALEELUR (PT)
Entity Type:Individual
Prefix:MR
First Name:KHALEELUR
Middle Name:
Last Name:ZACKARIYA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51280 EAGLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-4700
Mailing Address - Country:US
Mailing Address - Phone:574-277-5524
Mailing Address - Fax:574-970-4698
Practice Address - Street 1:333 W MISHAWAKA RD
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46517-1921
Practice Address - Country:US
Practice Address - Phone:574-293-1550
Practice Address - Fax:574-970-4698
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05006993A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist