Provider Demographics
NPI:1720086366
Name:ZELLER, CHARLES J IV (DO)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:J
Last Name:ZELLER
Suffix:IV
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 NW 49TH ST STE 125
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-3750
Mailing Address - Country:US
Mailing Address - Phone:954-888-3800
Mailing Address - Fax:954-888-3808
Practice Address - Street 1:1801 W SAMPLE RD STE 101
Practice Address - Street 2:
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33064-1370
Practice Address - Country:US
Practice Address - Phone:954-888-3800
Practice Address - Fax:954-888-3808
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002597A207Y00000X
OH34-00-7236-Z207YX0905X
FLOS14031207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017597600Medicaid
IN000000793244OtherANTHEM
IN200431240Medicaid
FL017597600Medicaid
OH2402493Medicaid
FL017597600Medicaid
INP01291605OtherMEDICARE RR PTAN
OH2402493Medicaid