Healthcare Provider Details

I. General information

NPI: 1487216974
Provider Name (Legal Business Name): MATTHEW ZACHARY ZUCKERT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2019
Last Update Date: 08/29/2021
Certification Date: 08/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3850 CRENSHAW BLVD
LOS ANGELES CA
90008-1821
US

IV. Provider business mailing address

23052H ALICIA PKWY # 118
MISSION VIEJO CA
92692-1636
US

V. Phone/Fax

Practice location:
  • Phone: 323-593-5300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: