Provider Demographics
NPI:1255339057
Name:ZICKAFOOSE, DAVID E (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:E
Last Name:ZICKAFOOSE
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 1:220 POTOMAC AVE
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:PA
Mailing Address - Zip Code:17331-2260
Mailing Address - Country:US
Mailing Address - Phone:717-632-5245
Mailing Address - Fax:717-632-9454
Practice Address - Street 1:220 POTOMAC AVE
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:PA
Practice Address - Zip Code:17331-2260
Practice Address - Country:US
Practice Address - Phone:717-632-5245
Practice Address - Fax:717-632-9454
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2009-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD010727E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA02323400OtherKEYSTONE HEALTH PLAN CENT
PA01131101OtherCAPITAL BLUE CROSS
PA000593938Medicaid
PA8121070OtherCIGNA
PA010768OtherICHP
PA02323400OtherCAPITAL BLUE CROSS
PAZI18669OtherHIGHMARK BLUE SHIELD
PA010768OtherICHP
PAB33176Medicare UPIN
PAZI18669Medicare ID - Type Unspecified
PA018669Medicare PIN