=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730170234
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOEL ZACKS MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2005
-----------------------------------------------------
Last Update Date | 04/23/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15914 JEANETTE ST
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48075-2013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-376-6046
-----------------------------------------------------
Fax | 248-569-7054
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15914 JEANETTE ST
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48075-2013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-569-7054
-----------------------------------------------------
Fax | 248-569-7054
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 036726
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------