Provider Demographics
NPI:1124020110
Name:ZADINA, SIMON P (MD)
Entity Type:Individual
Prefix:
First Name:SIMON
Middle Name:P
Last Name:ZADINA
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 1:703 LILLY RD NE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5191
Mailing Address - Country:US
Mailing Address - Phone:360-350-0281
Mailing Address - Fax:360-918-8280
Practice Address - Street 1:703 LILLY RD NE
Practice Address - Street 2:SUITE 106
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5191
Practice Address - Country:US
Practice Address - Phone:360-350-0281
Practice Address - Fax:360-918-8280
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN33196208800000X
WAMD6011602208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0259730OtherL&I
MN208800000XMedicaid
MN208800000XMedicaid
WAG8888956Medicare PIN
WA0259730OtherL&I