Provider Demographics
NPI:1619163078
Name:JASON A. ZACKS, MD PC
Entity type:Organization
Organization Name:JASON A. ZACKS, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GLENDA
Authorized Official - Middle Name:A
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:CMA
Authorized Official - Phone:334-678-1400
Mailing Address - Street 1:1920 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-3008
Mailing Address - Country:US
Mailing Address - Phone:334-678-1400
Mailing Address - Fax:334-678-1432
Practice Address - Street 1:1920 FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-3008
Practice Address - Country:US
Practice Address - Phone:334-678-1400
Practice Address - Fax:334-678-1432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-19
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALG64013261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALG64013Medicare UPIN
ALK711Medicare PIN