Basic Information
| Provider Information | |||||||||
| NPI: | 1235360769 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ZAKAS | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2680 S VAL VISTA DR | ||||||||
| Address2: | BLDG 9 STE 146 | ||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852952152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669742673 | ||||||||
| FaxNumber: | 8669392673 | ||||||||
| Practice Location | |||||||||
| Address1: | 18444 N 25TH AVE | ||||||||
| Address2: | 310 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850231261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6234743696 | ||||||||
| FaxNumber: | 6235445531 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2009 | ||||||||
| LastUpdateDate: | 03/12/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | SL0674 | NV | N | Other Service Providers | Specialist | 208100000X | 006081 | AZ | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 174400000X | 006081 | AZ | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 839589 | 05 | AZ | MEDICAID |