Healthcare Provider Details

I. General information

NPI: 1003828435
Provider Name (Legal Business Name): CATHY J ZACK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 05/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 MAIN ST
EAST HAMPTON CT
06424-1123
US

IV. Provider business mailing address

4 FARM SPRINGS RD PROHEALTH PHYSICIANS
FARMINGTON CT
06032-2573
US

V. Phone/Fax

Practice location:
  • Phone: 860-267-2593
  • Fax: 860-267-4889
Mailing address:
  • Phone: 860-284-5200
  • Fax: 860-284-5333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number030910
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number30910
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: