Provider Demographics
NPI:1356460018
Name:ZALLA, MARK J (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:J
Last Name:ZALLA
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 1:7766 EWING BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042-7538
Mailing Address - Country:US
Mailing Address - Phone:859-283-1033
Mailing Address - Fax:859-283-1066
Practice Address - Street 1:7766 EWING BLVD
Practice Address - Street 2:STE 100
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-7538
Practice Address - Country:US
Practice Address - Phone:859-283-1033
Practice Address - Fax:859-283-1066
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY35119207N00000X, 207ND0101X
KYK35119207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000223589OtherANTHEM ID
2815155OtherAETNA ID
03-20159OtherUNITED HEALTHCARE ID
KY1182304Medicare ID - Type Unspecified
03-20159OtherUNITED HEALTHCARE ID