Provider Demographics
NPI:1629182282
Name:ZOLLINGER, CHARLES JEFFREY (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:JEFFREY
Last Name:ZOLLINGER
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 1:393 E 2ND N
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-1605
Mailing Address - Country:US
Mailing Address - Phone:208-356-5401
Mailing Address - Fax:208-356-3111
Practice Address - Street 1:393 E 2ND N
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1605
Practice Address - Country:US
Practice Address - Phone:208-356-5401
Practice Address - Fax:208-356-3111
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM4211208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID004021800Medicaid
ID004021800Medicaid
D93688Medicare UPIN