Provider Demographics
NPI:1710955299
Name:ZELLER, COREY J (MD)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:J
Last Name:ZELLER
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 1:701 GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:WILD ROSE
Mailing Address - State:WI
Mailing Address - Zip Code:54984-6901
Mailing Address - Country:US
Mailing Address - Phone:920-622-5560
Mailing Address - Fax:
Practice Address - Street 1:701 GROVE AVE
Practice Address - Street 2:
Practice Address - City:WILD ROSE
Practice Address - State:WI
Practice Address - Zip Code:54984-6901
Practice Address - Country:US
Practice Address - Phone:920-622-5560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI47141207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI207Q00000XMedicaid
WIK400124623Medicare PIN