Healthcare Provider Details

I. General information

NPI: 1497702559
Provider Name (Legal Business Name): ILAN JEFFREY ZUK PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7807 CONVOY COURT STE 100
SAN DIEGO CA
92111-1213
US

IV. Provider business mailing address

PO BOX 609001
SAN DIEGO CA
92160-9001
US

V. Phone/Fax

Practice location:
  • Phone: 858-571-5437
  • Fax: 858-571-2801
Mailing address:
  • Phone: 619-528-4600
  • Fax: 619-528-4625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY19892
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: