Provider Demographics
NPI:1619959145
Name:ZOLKOWSKI, GREGORY STANLEY (DO)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:STANLEY
Last Name:ZOLKOWSKI
Suffix:
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:PO BOX 536
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-0536
Mailing Address - Country:US
Mailing Address - Phone:417-777-4749
Mailing Address - Fax:417-777-8041
Practice Address - Street 1:910 E SAN MARTIN ST
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-2893
Practice Address - Country:US
Practice Address - Phone:417-777-4749
Practice Address - Fax:417-777-8041
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-11776207P00000X, 207Q00000X
MO101186207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1619959145Medicaid
MO244710802Medicaid
P00786258OtherRR MEDICARE
MO1619959145Medicaid
MO501150002Medicare PIN
MO244710802Medicaid
P00786258OtherRR MEDICARE