Provider Demographics
NPI:1336195288
Name:ZIARKO, MITCHELL JACOB (MD)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:JACOB
Last Name:ZIARKO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6308 8TH AVENUE
Mailing Address - Street 2:SUITE 2000
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143
Mailing Address - Country:US
Mailing Address - Phone:262-653-5300
Mailing Address - Fax:262-653-5412
Practice Address - Street 1:6308 8TH AVENUE
Practice Address - Street 2:SUITE 2000
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143
Practice Address - Country:US
Practice Address - Phone:262-653-5300
Practice Address - Fax:262-653-5412
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21900207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30178400Medicaid
WI30178400Medicaid