Healthcare Provider Details

I. General information

NPI: 1124395421
Provider Name (Legal Business Name): DR. MICHAEL JEFFREY ZIZMOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2011
Last Update Date: 10/21/2021
Certification Date: 10/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2831 MACDONALD AVE
RICHMOND CA
94804-3008
US

IV. Provider business mailing address

2831 MACDONALD AVE
RICHMOND CA
94804-3008
US

V. Phone/Fax

Practice location:
  • Phone: 510-236-5340
  • Fax: 510-236-5340
Mailing address:
  • Phone: 510-236-5340
  • Fax: 510-236-5340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License NumberG50848
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberG50848
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: