Provider Demographics
NPI:1851377923
Name:ZIEBARTH, THOMAS MATTHEW (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:MATTHEW
Last Name:ZIEBARTH
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 1:507 W DOUGHTY ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55041-1500
Mailing Address - Country:US
Mailing Address - Phone:651-345-2350
Mailing Address - Fax:651-345-2238
Practice Address - Street 1:507 W DOUGHTY ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:MN
Practice Address - Zip Code:55041-1500
Practice Address - Country:US
Practice Address - Phone:651-345-2350
Practice Address - Fax:651-345-2238
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN37579207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN456723400Medicaid
080006488Medicare ID - Type Unspecified
MN456723400Medicaid