Provider Demographics
NPI:1083614432
Name:ZEDDIES, CLARK A (MD)
Entity Type:Individual
Prefix:DR
First Name:CLARK
Middle Name:A
Last Name:ZEDDIES
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:PO BOX 713260
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-1260
Mailing Address - Country:US
Mailing Address - Phone:630-469-9200
Mailing Address - Fax:
Practice Address - Street 1:455 BRIARGATE DR STE 100
Practice Address - Street 2:
Practice Address - City:SOUTH ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60177-2225
Practice Address - Country:US
Practice Address - Phone:847-622-0506
Practice Address - Fax:847-622-0507
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036077324207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036077324Medicaid
IL036077324Medicaid
ILC42773Medicare UPIN