Healthcare Provider Details

I. General information

NPI: 1124020110
Provider Name (Legal Business Name): SIMON P ZADINA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 02/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 LILLY RD NE SUITE 106
OLYMPIA WA
98506-5191
US

IV. Provider business mailing address

703 LILLY RD NE SUITE 106
OLYMPIA WA
98506-5191
US

V. Phone/Fax

Practice location:
  • Phone: 360-350-0281
  • Fax: 360-918-8280
Mailing address:
  • Phone: 360-350-0281
  • Fax: 360-918-8280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number33196
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberMD6011602
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: