Healthcare Provider Details

I. General information

NPI: 1558399469
Provider Name (Legal Business Name): MARK ALAN ZOLLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 07/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3690 SAINT JOHNS BLUFF RD S
JACKSONVILLE FL
32224-2616
US

IV. Provider business mailing address

3690 SAINT JOHNS BLUFF RD S
JACKSONVILLE FL
32224-2616
US

V. Phone/Fax

Practice location:
  • Phone: 904-645-6767
  • Fax: 904-645-0145
Mailing address:
  • Phone: 904-645-6767
  • Fax: 904-645-0145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME0051029
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: