Provider Demographics
NPI:1427491968
Name:ZIDOVETZKI, SAMUEL JACOB (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:JACOB
Last Name:ZIDOVETZKI
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 1:600 HIGHLAND AVE
Mailing Address - Street 2:H4/831
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53792-0001
Mailing Address - Country:US
Mailing Address - Phone:608-890-8682
Mailing Address - Fax:
Practice Address - Street 1:600 HIGHLAND AVE
Practice Address - Street 2:H4/831
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53792
Practice Address - Country:US
Practice Address - Phone:608-890-8682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-15
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA155123207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine