Healthcare Provider Details

I. General information

NPI: 1710377395
Provider Name (Legal Business Name): MAC ZIMDARS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2015
Last Update Date: 02/28/2024
Certification Date: 02/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E BROADWAY STE 400
EUGENE OR
97401-3104
US

IV. Provider business mailing address

4186 VICTORIA LN
EUGENE OR
97404-4079
US

V. Phone/Fax

Practice location:
  • Phone: 541-357-9764
  • Fax:
Mailing address:
  • Phone: 858-829-6750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3728
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: