Healthcare Provider Details

I. General information

NPI: 1306306196
Provider Name (Legal Business Name): ZACHARY BLAZE WUNROW MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2019
Last Update Date: 12/05/2023
Certification Date: 12/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

791 JONESTOWN RD
WINSTON SALEM NC
27103-1252
US

IV. Provider business mailing address

100 KIMEL FOREST DR
WINSTON SALEM NC
27103-6074
US

V. Phone/Fax

Practice location:
  • Phone: 336-716-4551
  • Fax: 336-716-9642
Mailing address:
  • Phone: 336-713-0947
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2023-01038
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: