Healthcare Provider Details

I. General information

NPI: 1639286347
Provider Name (Legal Business Name): KENNETH PHILIP ZUCKERMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16300 SAND CANYON AVE SUITE 704
IRVINE CA
92618-3711
US

IV. Provider business mailing address

16300 SAND CANYON AVE SUITE 704
IRVINE CA
92618-3711
US

V. Phone/Fax

Practice location:
  • Phone: 949-753-0112
  • Fax:
Mailing address:
  • Phone: 949-753-0112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberG48414
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: