Provider Demographics
NPI:1558399469
Name:ZOLLER, MARK ALAN (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:ZOLLER
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 1:3690 SAINT JOHNS BLUFF RD S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-2616
Mailing Address - Country:US
Mailing Address - Phone:904-645-6767
Mailing Address - Fax:904-645-0145
Practice Address - Street 1:3690 SAINT JOHNS BLUFF RD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-2616
Practice Address - Country:US
Practice Address - Phone:904-645-6767
Practice Address - Fax:904-645-0145
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0051029207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD61102Medicare UPIN
FL04555WMedicare PIN