Basic Information
| Provider Information | |||||||||
| NPI: | 1114960820 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ZELLER | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2110 LEITER RD | ||||||||
| Address2: | |||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453423660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373844838 | ||||||||
| FaxNumber: | 9373844845 | ||||||||
| Practice Location | |||||||||
| Address1: | 1045 CHANNINGWAY DR. | ||||||||
| Address2: | |||||||||
| City: | FAIRBORN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453249244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9378788644 | ||||||||
| FaxNumber: | 9378788646 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 04/03/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 34.002882 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0627147 | 05 | OH | MEDICAID |