Provider Demographics
NPI:1336895689
Name:ZUCKERMAN, CHRISTINA MICHELLE
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:MICHELLE
Last Name:ZUCKERMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 AVENUE D
Mailing Address - Street 2:
Mailing Address - City:LAKE RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-1902
Mailing Address - Country:US
Mailing Address - Phone:631-478-3125
Mailing Address - Fax:
Practice Address - Street 1:253 BROADWAY
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-2712
Practice Address - Country:US
Practice Address - Phone:631-598-0009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-24
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027945207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty