=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609654466
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIVE OAK DERMATOLOGY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2023
-----------------------------------------------------
Last Update Date | 01/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7176 W RIDGE RD
-----------------------------------------------------
City | FAIRVIEW
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16415-2027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-413-7997
-----------------------------------------------------
Fax | 814-413-7998
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7176 W RIDGE RD
-----------------------------------------------------
City | FAIRVIEW
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16415-2027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-413-7997
-----------------------------------------------------
Fax | 814-413-7998
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MICHAEL ZAYCOSKY
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 814-413-7997
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ND0101X
-----------------------------------------------------
Taxonomy Name | MOHS-Micrographic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------