Provider Demographics
NPI:1366539165
Name:ZINZILIETA, J. MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:J.
Middle Name:MICHAEL
Last Name:ZINZILIETA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:M
Other - Last Name:ZINZILIETA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1025 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703-2403
Mailing Address - Country:US
Mailing Address - Phone:217-528-7541
Mailing Address - Fax:
Practice Address - Street 1:900 N. 1ST STREET
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-3749
Practice Address - Country:US
Practice Address - Phone:217-528-7541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-059290207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036059290Medicaid
IL036059290Medicaid
K24327Medicare ID - Type Unspecified