Provider Demographics
NPI:1609654466
Name:LIVE OAK DERMATOLOGY PC
Entity type:Organization
Organization Name:LIVE OAK DERMATOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ZAYCOSKY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:814-413-7997
Mailing Address - Street 1:7176 W RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:PA
Mailing Address - Zip Code:16415-2027
Mailing Address - Country:US
Mailing Address - Phone:814-413-7997
Mailing Address - Fax:814-413-7998
Practice Address - Street 1:7176 W RIDGE RD
Practice Address - Street 2:
Practice Address - City:FAIRVIEW
Practice Address - State:PA
Practice Address - Zip Code:16415-2027
Practice Address - Country:US
Practice Address - Phone:814-413-7997
Practice Address - Fax:814-413-7998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-21
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAOS015047OtherSTATE LIC