Healthcare Provider Details

I. General information

NPI: 1245268168
Provider Name (Legal Business Name): MARC JAY ZUCKERMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 12/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 ALBERTA AVE.
EL PASO TX
79905
US

IV. Provider business mailing address

PO BOX 9520
EL PASO TX
79995-9520
US

V. Phone/Fax

Practice location:
  • Phone: 915-545-6647
  • Fax: 915-545-9799
Mailing address:
  • Phone: 915-545-9795
  • Fax: 915-545-9799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG6251
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberG6251
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: