Provider Demographics
NPI:1174563209
Name:ZOLLER, KENNETH M (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:M
Last Name:ZOLLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 WESTGATE DR
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-1818
Mailing Address - Country:US
Mailing Address - Phone:508-587-0700
Mailing Address - Fax:508-587-0287
Practice Address - Street 1:375 WESTGATE DR
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-1818
Practice Address - Country:US
Practice Address - Phone:508-587-0700
Practice Address - Fax:508-587-0287
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA38302207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0128252Medicaid
MABLUE CROSS/SHIELDOtherJ03214
MAUNITED HEALTH CAREOther31-02002
MAAETNAOther0597915
MAHARVARD PILGRIMOther10306
MAHEALTH NETOther000000005592
MATUFTSOther038302
MATUFTSOther038302
MAAETNAOther0597915