Provider Demographics
NPI:1750486460
Name:ZOLLICOFFER, CHARLES MCKINLEY (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:MCKINLEY
Last Name:ZOLLICOFFER
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 1:5827 CORPORATE WAY
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-2000
Mailing Address - Country:US
Mailing Address - Phone:561-844-9443
Mailing Address - Fax:561-472-9692
Practice Address - Street 1:1871 SE TIFFANY AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7585
Practice Address - Country:US
Practice Address - Phone:772-337-4000
Practice Address - Fax:772-335-4054
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY231571207V00000X
FLME 97653207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL278332100Medicaid
FLME97653OtherLICENSE
FLME97653OtherLICENSE
FL278332100Medicaid