Provider Demographics
NPI:1881658953
Name:ZACKS, MARK N (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:N
Last Name:ZACKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:8619 W GRAND RIVER AVE
Mailing Address - Street 2:STE. J
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48116-2334
Mailing Address - Country:US
Mailing Address - Phone:810-227-6793
Mailing Address - Fax:810-227-5397
Practice Address - Street 1:8619 W GRAND RIVER AVE
Practice Address - Street 2:STE. J
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-2334
Practice Address - Country:US
Practice Address - Phone:810-227-6793
Practice Address - Fax:810-227-5397
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIMZ035093207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1144084Other1ST HEALTH
MIM011067OtherCHAMPUS
MI93648AOtherHAP
MI11217890OtherAETNA
MI4840320Medicaid
MI700D711040OtherBCBSM &BCN
MIB45174Medicare UPIN
MIP28930001Medicare ID - Type Unspecified