Provider Demographics
NPI:1720197759
Name:ZACKS, YAAKOV GERSHON (OD)
Entity Type:Individual
Prefix:DR
First Name:YAAKOV
Middle Name:GERSHON
Last Name:ZACKS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16232 SHERFIELD PL
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-2061
Mailing Address - Country:US
Mailing Address - Phone:248-552-1323
Mailing Address - Fax:
Practice Address - Street 1:16232 SHERFIELD PL
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2061
Practice Address - Country:US
Practice Address - Phone:248-376-6046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004402152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4553823Medicaid