Healthcare Provider Details

I. General information

NPI: 1336895689
Provider Name (Legal Business Name): CHRISTINA MICHELLE ZUCKERMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2022
Last Update Date: 02/24/2022
Certification Date: 02/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

253 BROADWAY
AMITYVILLE NY
11701-2712
US

IV. Provider business mailing address

40 AVENUE D
LAKE RONKONKOMA NY
11779-1902
US

V. Phone/Fax

Practice location:
  • Phone: 631-598-0009
  • Fax:
Mailing address:
  • Phone: 631-478-3125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number027945
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: