Provider Demographics
NPI:1730170234
Name:ZACKS, JOEL (MD)
Entity type:Individual
Prefix:DR
First Name:JOEL
Middle Name:
Last Name:ZACKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:15914 JEANETTE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-2013
Mailing Address - Country:US
Mailing Address - Phone:248-569-7054
Mailing Address - Fax:248-569-7054
Practice Address - Street 1:15914 JEANETTE ST
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2013
Practice Address - Country:US
Practice Address - Phone:248-376-6046
Practice Address - Fax:248-569-7054
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI036726207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1045538230Medicaid
MI1045538230Medicaid
MIA77015Medicare UPIN