Provider Demographics
NPI:1932120573
Name:ZASULY, JAMES M (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:M
Last Name:ZASULY
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 1:2845 GREENBRIER RD STE 230
Mailing Address - Street 2:PO BOX 8900
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54308-8900
Mailing Address - Country:US
Mailing Address - Phone:920-288-8240
Mailing Address - Fax:920-288-8255
Practice Address - Street 1:2605 DEVELOPMENT DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-4240
Practice Address - Country:US
Practice Address - Phone:920-288-8240
Practice Address - Fax:920-857-1488
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI43535208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34113800Medicaid
WI34113800Medicaid
WI013607650Medicare ID - Type Unspecified