Provider Demographics
NPI:1770544629
Name:ZOLDAN, JACK S (MD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:S
Last Name:ZOLDAN
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 1:5015 N PAULINA ST
Mailing Address - Street 2:SUITE 315
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-2756
Mailing Address - Country:US
Mailing Address - Phone:773-561-6573
Mailing Address - Fax:773-561-8323
Practice Address - Street 1:5015 N PAULINA ST
Practice Address - Street 2:SUITE 315
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-2756
Practice Address - Country:US
Practice Address - Phone:773-561-6573
Practice Address - Fax:773-561-8323
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036053375174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036053375Medicaid
ILD13760Medicare UPIN
IL200973Medicare ID - Type Unspecified