Provider Demographics
NPI:1356829006
Name:MILLER, ZACKARY DAVID (LMT)
Entity type:Individual
Prefix:MR
First Name:ZACKARY
Middle Name:DAVID
Last Name:MILLER
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:482 SHELDON RD APT 8
Mailing Address - Street 2:
Mailing Address - City:FREEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13068-9773
Mailing Address - Country:US
Mailing Address - Phone:607-242-2404
Mailing Address - Fax:
Practice Address - Street 1:821 CLIFF ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-2097
Practice Address - Country:US
Practice Address - Phone:607-256-9355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-04
Last Update Date:2018-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030830225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist