Provider Demographics
NPI:1104096270
Name:ZASTROW, JED L (DC)
Entity type:Individual
Prefix:
First Name:JED
Middle Name:L
Last Name:ZASTROW
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18775 N REEMS RD STE 360
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-8647
Mailing Address - Country:US
Mailing Address - Phone:623-975-0888
Mailing Address - Fax:
Practice Address - Street 1:18775 N REEMS RD STE 360
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-8647
Practice Address - Country:US
Practice Address - Phone:623-975-0888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-05
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7545111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZV04722Medicare UPIN
AZZ102638Medicare PIN