Provider Demographics
NPI:1801983242
Name:ZUCKER, STEPHEN EDWARD (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:EDWARD
Last Name:ZUCKER
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 1:621 MEMORIAL DR
Mailing Address - Street 2:SUITE 511
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-1063
Mailing Address - Country:US
Mailing Address - Phone:574-232-3919
Mailing Address - Fax:574-233-1063
Practice Address - Street 1:621 MEMORIAL DR
Practice Address - Street 2:SUITE 511
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1063
Practice Address - Country:US
Practice Address - Phone:574-232-3919
Practice Address - Fax:574-233-1063
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01034163174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100224080Medicaid
INC25591Medicare UPIN
IN739920Medicare ID - Type UnspecifiedMEDICARE