Basic Information
| Provider Information | |||||||||
| NPI: | 1932543113 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ZUCK | ||||||||
| FirstName: | LINDSAY | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOHNSON | ||||||||
| OtherFirstName: | LINDSAY | ||||||||
| OtherMiddleName: | K | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 100 S BLISS AVE | ||||||||
| Address2: | |||||||||
| City: | TAHLEQUAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744642512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184583100 | ||||||||
| FaxNumber: | 9184583610 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 S BLISS AVE | ||||||||
| Address2: | |||||||||
| City: | TAHLEQUAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744642512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184583100 | ||||||||
| FaxNumber: | 9184583610 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2013 | ||||||||
| LastUpdateDate: | 05/02/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 6078 | OK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.