Healthcare Provider Details

I. General information

NPI: 1265792386
Provider Name (Legal Business Name): MATTHEW WILLIAM ZACKOFF M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2012
Last Update Date: 07/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 BURNET AVE ML 5012
CINCINNATI OH
45229-3026
US

IV. Provider business mailing address

3333 BURNET AVE ML 5012
CINCINNATI OH
45229-3026
US

V. Phone/Fax

Practice location:
  • Phone: 513-636-4315
  • Fax: 513-636-7905
Mailing address:
  • Phone: 513-636-4315
  • Fax: 513-636-7905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35.125832
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number35.125832
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: