Provider Demographics
NPI:1730101635
Name:ZOMBACK, NEAL BRADLEY (DPM)
Entity Type:Individual
Prefix:
First Name:NEAL
Middle Name:BRADLEY
Last Name:ZOMBACK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:478 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHESHIRE
Mailing Address - State:CT
Mailing Address - Zip Code:06410-3117
Mailing Address - Country:US
Mailing Address - Phone:203-250-0505
Mailing Address - Fax:203-651-0049
Practice Address - Street 1:478 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CHESHIRE
Practice Address - State:CT
Practice Address - Zip Code:06410-3117
Practice Address - Country:US
Practice Address - Phone:203-250-0505
Practice Address - Fax:203-651-0049
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT466213ES0000X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004090528Medicaid