Provider Demographics
NPI:1649697103
Name:ZOLG, JAMES LEO
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:LEO
Last Name:ZOLG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3840 CASSIA DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-7711
Mailing Address - Country:US
Mailing Address - Phone:407-737-0926
Mailing Address - Fax:407-737-0926
Practice Address - Street 1:3840 CASSIA DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-7711
Practice Address - Country:US
Practice Address - Phone:407-737-0926
Practice Address - Fax:407-737-0926
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-23
Last Update Date:2014-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL7G 427 A253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009876000Medicaid