Provider Demographics
NPI:1386838340
Name:ZACHARIAH, PHENU V (DO)
Entity type:Individual
Prefix:
First Name:PHENU
Middle Name:V
Last Name:ZACHARIAH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:
Practice Address - Street 1:1151 WARWICK WAY
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-5661
Practice Address - Country:US
Practice Address - Phone:262-321-6300
Practice Address - Fax:262-321-6301
Is Sole Proprietor?:No
Enumeration Date:2007-09-04
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010020902207RE0101X
WI70454207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100084384Medicaid
MO1598759169Medicaid
MOP00866350OtherRR MEDICARE