Provider Demographics
NPI:1689962904
Name:ZIDEK, AMBER DAWN
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:DAWN
Last Name:ZIDEK
Suffix:
Gender:F
Credentials:
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 5171
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77903-5171
Mailing Address - Country:US
Mailing Address - Phone:361-582-0611
Mailing Address - Fax:361-582-4978
Practice Address - Street 1:4208 RETAMA CIR
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901-2765
Practice Address - Country:US
Practice Address - Phone:361-582-0611
Practice Address - Fax:361-582-4978
Is Sole Proprietor?:No
Enumeration Date:2011-07-20
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX114284225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist