Healthcare Provider Details

I. General information

NPI: 1366978918
Provider Name (Legal Business Name): JOSEPH ZIKRY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2017
Last Update Date: 03/23/2022
Certification Date: 03/23/2022
Deactivation Date: 06/11/2018
Reactivation Date: 06/27/2018

III. Provider practice location address

1811 WILSHIRE BLVD STE 110
SANTA MONICA CA
90403-5626
US

IV. Provider business mailing address

1811 WILSHIRE BLVD STE 110
SANTA MONICA CA
90403-5626
US

V. Phone/Fax

Practice location:
  • Phone: 310-829-0260
  • Fax:
Mailing address:
  • Phone: 310-829-0260
  • Fax: 310-829-0263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA159681
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: