Provider Demographics
NPI:1790722965
Name:ZIMOSTRAD, SCOTT WILLIAM (PHD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:WILLIAM
Last Name:ZIMOSTRAD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:728 W WACKERLY ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-4703
Mailing Address - Country:US
Mailing Address - Phone:989-839-6565
Mailing Address - Fax:989-839-5794
Practice Address - Street 1:728 W WACKERLY ST
Practice Address - Street 2:SUITE 1
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-4703
Practice Address - Country:US
Practice Address - Phone:989-839-6565
Practice Address - Fax:989-839-5794
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301004028103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0E64565OtherBCBS OF MICHIGAN
MI0E64565OtherBCBS OF MICHIGAN