Basic Information
| Provider Information | |||||||||
| NPI: | 1750486460 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ZOLLICOFFER | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | MCKINLEY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5827 CORPORATE WAY | ||||||||
| Address2: | |||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334072000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5618449443 | ||||||||
| FaxNumber: | 5614729692 | ||||||||
| Practice Location | |||||||||
| Address1: | 1871 SE TIFFANY AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PORT ST LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349527585 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7723374000 | ||||||||
| FaxNumber: | 7723354054 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 03/19/2019 | ||||||||
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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 | 207V00000X | 231571 | NY | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | ME 97653 | FL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 278332100 | 05 | FL | MEDICAID | ME97653 | 01 | FL | LICENSE | OTHER |