Basic Information
Provider Information | |||||||||
NPI: | 1669447421 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ZOLLER | ||||||||
FirstName: | GREGORY | ||||||||
MiddleName: | W | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1241 W MINERAL AVE | ||||||||
Address2: |   | ||||||||
City: | LITTLETON | ||||||||
State: | CO | ||||||||
PostalCode: | 801205685 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3037590854 | ||||||||
FaxNumber: | 3037590864 | ||||||||
Practice Location | |||||||||
Address1: | 7700 S BROADWAY | ||||||||
Address2: | LITTLETON ADVENTIST HOSPITAL | ||||||||
City: | LITTLETON | ||||||||
State: | CO | ||||||||
PostalCode: | 801222602 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3037305800 | ||||||||
FaxNumber: | 3037305868 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/22/2006 | ||||||||
LastUpdateDate: | 04/23/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 22333 | CO | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 01223338 | 05 | CO |   | MEDICAID | 930007474 | 01 | CO | RR MEDICARE | OTHER |