Provider Demographics
NPI:1720543705
Name:ZAJICEK, SAMUEL TYLER
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:TYLER
Last Name:ZAJICEK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 S RIALTO UNIT 13
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-3773
Mailing Address - Country:US
Mailing Address - Phone:402-416-4580
Mailing Address - Fax:
Practice Address - Street 1:255 W BROWN RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-3404
Practice Address - Country:US
Practice Address - Phone:480-833-3988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-04
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist