Healthcare Provider Details

I. General information

NPI: 1730132887
Provider Name (Legal Business Name): KENNETH E. ZICHAL M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 01/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911 CARTER ST NW
ELKADER IA
52043-9016
US

IV. Provider business mailing address

1500 ASSOCIATES DR
DUBUQUE IA
52002-2201
US

V. Phone/Fax

Practice location:
  • Phone: 563-245-1746
  • Fax: 563-245-2066
Mailing address:
  • Phone: 563-584-4100
  • Fax: 563-584-4110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20215
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number29117
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: