Healthcare Provider Details

I. General information

NPI: 1083715510
Provider Name (Legal Business Name): CHARLES WALLACE ZOLLMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8227 NORTHWEST BLVD SUITE 290
INDIANAPOLIS IN
46278-1387
US

IV. Provider business mailing address

8227 NORTHWEST BLVD SUITE 290
INDIANAPOLIS IN
46278-1387
US

V. Phone/Fax

Practice location:
  • Phone: 317-328-1100
  • Fax: 317-334-9228
Mailing address:
  • Phone: 317-328-1100
  • Fax: 317-334-9228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number01023513A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: