Provider Demographics
NPI:1760599013
Name:ZACK, MICHAEL BRANDON
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BRANDON
Last Name:ZACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10532 N PORT WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-5563
Mailing Address - Country:US
Mailing Address - Phone:262-240-1600
Mailing Address - Fax:262-240-1602
Practice Address - Street 1:10532 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-5563
Practice Address - Country:US
Practice Address - Phone:262-240-1600
Practice Address - Fax:262-240-1602
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2008-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4134-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38967100Medicaid
WIV07269Medicare UPIN
WI38967100Medicaid