Basic Information
| Provider Information | |||||||||
| NPI: | 1528076882 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CARL ZOLLICOFFER MD PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GRACE WOMENS HEALTHCARE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2401 FRIST BLVD | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | FORT PIERCE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349504839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7724293400 | ||||||||
| FaxNumber: | 7724293410 | ||||||||
| Practice Location | |||||||||
| Address1: | 2401 FRIST BLVD | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | FORT PIERCE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349504839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7724293400 | ||||||||
| FaxNumber: | 7724293410 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 10/04/2007 | ||||||||
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| AuthorizedOfficialLastName: | ZOLLICOFFER | ||||||||
| AuthorizedOfficialFirstName: | CARL | ||||||||
| AuthorizedOfficialMiddleName: | DONNELL | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7724293400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.