Basic Information
Provider Information | |||||||||
NPI: | 1548371289 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ZAK | ||||||||
FirstName: | DMITRIY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 800 ENERGY CENTER BLVD | ||||||||
Address2: | APT. 2419 | ||||||||
City: | NORTHPORT | ||||||||
State: | AL | ||||||||
PostalCode: | 35473 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9176717938 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 628 HOSPITAL DRIVE | ||||||||
Address2: | GROUND FLOOR SUITE A | ||||||||
City: | MOUNTAIN HOME | ||||||||
State: | AR | ||||||||
PostalCode: | 72653 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8704254402 | ||||||||
FaxNumber: | 8704256811 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/31/2006 | ||||||||
LastUpdateDate: | 06/09/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/21/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 2275741 | NY | N |   | Other Service Providers | Specialist |   | 207RH0003X | 32345 | AL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
No ID Information.