Provider Demographics
NPI:1083614549
Name:ZEDELIS, ROBERT V (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:V
Last Name:ZEDELIS
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 6860
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95502-6860
Mailing Address - Country:US
Mailing Address - Phone:707-443-3384
Mailing Address - Fax:707-443-3204
Practice Address - Street 1:2425 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-3218
Practice Address - Country:US
Practice Address - Phone:707-441-4420
Practice Address - Fax:707-269-3889
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG17001174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0065800Medicaid
CAA39969Medicare UPIN
CA00G170010Medicare ID - Type Unspecified