Provider Demographics
NPI:1245294354
Name:ZALESKI, MARK A (OWNER)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:ZALESKI
Suffix:
Gender:M
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:PA
Mailing Address - Zip Code:18337-1345
Mailing Address - Country:US
Mailing Address - Phone:570-296-4891
Mailing Address - Fax:570-296-4892
Practice Address - Street 1:322 BROAD ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:PA
Practice Address - Zip Code:18337-1345
Practice Address - Country:US
Practice Address - Phone:570-296-4891
Practice Address - Fax:570-296-4892
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-14
Last Update Date:2007-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100923Medicare PIN