Healthcare Provider Details

I. General information

NPI: 1962572982
Provider Name (Legal Business Name): VICENTE SANTIAGO ZATA JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 09/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 S WATER STREET
HARDIN IL
62047-0106
US

IV. Provider business mailing address

390 MAPLE SUMMIT RD
JERSEYVILLE IL
62052-2000
US

V. Phone/Fax

Practice location:
  • Phone: 618-576-9407
  • Fax: 618-576-2260
Mailing address:
  • Phone: 618-498-7518
  • Fax: 618-498-3052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036051832
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: