Basic Information
| Provider Information | |||||||||
| NPI: | 1801828157 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ZOLLER | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1515 N HARVARD AVE STE E | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741154904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9188326049 | ||||||||
| FaxNumber: | 9188326055 | ||||||||
| Practice Location | |||||||||
| Address1: | 133 N. FAIRLAND | ||||||||
| Address2: | |||||||||
| City: | PRYOR | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74361 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9188256600 | ||||||||
| FaxNumber: | 9182933158 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 06/05/2013 | ||||||||
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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 | 207RC0000X | 9468 | OK | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | P00295068 | 01 | OK | RR MEDICARE | OTHER | 100176170A | 05 | OK | MEDICAID |