Provider Demographics
NPI:1124276282
Name:ZEDALIS, KIMBERLY D
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:D
Last Name:ZEDALIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2780 MIDDLE COUNTRY RD
Mailing Address - Street 2:STE 210
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-2124
Mailing Address - Country:US
Mailing Address - Phone:631-588-4500
Mailing Address - Fax:631-588-4595
Practice Address - Street 1:2780 MIDDLE COUNTRY RD
Practice Address - Street 2:STE 210
Practice Address - City:LAKE GROVE
Practice Address - State:NY
Practice Address - Zip Code:11755-2124
Practice Address - Country:US
Practice Address - Phone:631-588-4500
Practice Address - Fax:631-588-4595
Is Sole Proprietor?:No
Enumeration Date:2008-09-03
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY956080247100000X, 2471M2300X
NY000142243U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes243U00000XTechnologists, Technicians & Other Technical Service ProvidersRadiology Practitioner Assistant
No247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist
No2471M2300XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMammography