Provider Demographics
NPI:1831156595
Name:ZUCKERMAN, SAMUEL L (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:L
Last Name:ZUCKERMAN
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 1:3100 CHANNING WAY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7533
Mailing Address - Country:US
Mailing Address - Phone:210-737-4928
Mailing Address - Fax:
Practice Address - Street 1:MOUNTAIN NEONATOLOGY LLC
Practice Address - Street 2:3100 CHANNING WAY
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7533
Practice Address - Country:US
Practice Address - Phone:602-346-7013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9854207LP3000X, 2080P0203X
IDM-154882080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX132776910Medicaid
OH200102900 AMedicaid
NM33787336Medicaid
TX132776912Medicaid
TX132776911Medicaid
NM33787336Medicaid