Provider Demographics
NPI:1205923976
Name:ZICK, ELIZABETH OWEN (MD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:OWEN
Last Name:ZICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 HATFIELD LN
Mailing Address - Street 2:SUITE 204
Mailing Address - City:GOSHEN
Mailing Address - State:NY
Mailing Address - Zip Code:10924-6766
Mailing Address - Country:US
Mailing Address - Phone:845-294-6927
Mailing Address - Fax:
Practice Address - Street 1:30 HATFIELD LN
Practice Address - Street 2:SUITE 204
Practice Address - City:GOSHEN
Practice Address - State:NY
Practice Address - Zip Code:10924-6766
Practice Address - Country:US
Practice Address - Phone:845-294-6927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY184161207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY63J581Medicare ID - Type Unspecified