Provider Demographics
NPI:1659123107
Name:ZACARESE, GREGORY (RD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:ZACARESE
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79-25 WINCHESTER BLVD, QUEENS VILLAGE, NY 11427
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11427
Mailing Address - Country:US
Mailing Address - Phone:718-264-4461
Mailing Address - Fax:
Practice Address - Street 1:17 WIMBLEDON DR
Practice Address - Street 2:
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576-3083
Practice Address - Country:US
Practice Address - Phone:151-683-0022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-05
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY86088710133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered