Healthcare Provider Details

I. General information

NPI: 1316999824
Provider Name (Legal Business Name): MICHAEL C ZACHARISEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 09/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4265 FALLON ST STE 3A
BOZEMAN MT
59718-6797
US

IV. Provider business mailing address

4265 FALLON ST STE 3A
BOZEMAN MT
59718-6797
US

V. Phone/Fax

Practice location:
  • Phone: 406-451-7017
  • Fax: 406-451-7020
Mailing address:
  • Phone: 406-451-7017
  • Fax: 406-451-7020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number12449
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: