Provider Demographics
NPI:1649439472
Name:ZELICKSON, MARC STUART (MD)
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:STUART
Last Name:ZELICKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2705
Mailing Address - Street 2:SUITE C
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35804-2705
Mailing Address - Country:US
Mailing Address - Phone:256-265-5951
Mailing Address - Fax:256-265-5952
Practice Address - Street 1:4025 PEPPERWOOD CIR SW
Practice Address - Street 2:SUITE C
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-7437
Practice Address - Country:US
Practice Address - Phone:256-882-1908
Practice Address - Fax:256-882-1907
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-06
Last Update Date:2016-06-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AL32718208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL150521Medicaid
SCRES000Medicare UPIN