Provider Demographics
NPI:1154304558
Name:ZOELLNER, LAURA J (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:J
Last Name:ZOELLNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 S EAGLE RD
Mailing Address - Street 2:SUITE 2207
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6354
Mailing Address - Country:US
Mailing Address - Phone:208-288-0989
Mailing Address - Fax:208-288-0976
Practice Address - Street 1:520 S EAGLE RD
Practice Address - Street 2:#2207
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6354
Practice Address - Country:US
Practice Address - Phone:208-288-0989
Practice Address - Fax:208-288-0976
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8106207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000010139256OtherBS
50427OtherBC
1103851Medicare ID - Type Unspecified
50427OtherBC