Provider Demographics
NPI:1114960820
Name:ZELLER, CHARLES J III (DO)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:J
Last Name:ZELLER
Suffix:III
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 LEITER RD
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-3660
Mailing Address - Country:US
Mailing Address - Phone:937-384-4838
Mailing Address - Fax:937-384-4845
Practice Address - Street 1:1045 CHANNINGWAY DR.
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-9244
Practice Address - Country:US
Practice Address - Phone:937-878-8644
Practice Address - Fax:937-878-8646
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.002882207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0627147Medicaid
OH0828093Medicare PIN
OH0500232Medicare PIN
OH0627147Medicaid