Provider Demographics
NPI:1083715510
Name:ZOLLMAN, CHARLES WALLACE (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:WALLACE
Last Name:ZOLLMAN
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 1:8227 NORTHWEST BLVD
Mailing Address - Street 2:SUITE 290
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46278-1387
Mailing Address - Country:US
Mailing Address - Phone:317-328-1100
Mailing Address - Fax:317-334-9228
Practice Address - Street 1:8227 NORTHWEST BLVD
Practice Address - Street 2:SUITE 290
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46278-1387
Practice Address - Country:US
Practice Address - Phone:317-328-1100
Practice Address - Fax:317-334-9228
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01023513A2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN232190AMedicare ID - Type Unspecified
INB28262Medicare UPIN