Healthcare Provider Details

I. General information

NPI: 1174563209
Provider Name (Legal Business Name): KENNETH M ZOLLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 WESTGATE DR
BROCKTON MA
02301-1818
US

IV. Provider business mailing address

375 WESTGATE DR
BROCKTON MA
02301-1818
US

V. Phone/Fax

Practice location:
  • Phone: 508-587-0700
  • Fax: 508-587-0287
Mailing address:
  • Phone: 508-587-0700
  • Fax: 508-587-0287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number38302
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: