Provider Demographics
NPI:1790774750
Name:ZAWACKI, JEFFREY K (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:K
Last Name:ZAWACKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3245 GROVE AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-3474
Mailing Address - Country:US
Mailing Address - Phone:708-484-0621
Mailing Address - Fax:708-484-0250
Practice Address - Street 1:3245 GROVE AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3474
Practice Address - Country:US
Practice Address - Phone:708-484-0621
Practice Address - Fax:708-484-0250
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036-089882208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036089882Medicaid
01619787OtherBCBSIL GROUP NUMBER
IL036089882Medicaid
ILG70944Medicare UPIN
IL036089882Medicaid