Provider Demographics
NPI:1194708776
Name:ZOELLER, DAVID J (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:ZOELLER
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 1:2413 RING RD STE 110
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-5924
Mailing Address - Country:US
Mailing Address - Phone:270-765-4535
Mailing Address - Fax:270-763-1901
Practice Address - Street 1:2413 RING RD STE 110
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-5924
Practice Address - Country:US
Practice Address - Phone:270-765-4535
Practice Address - Fax:270-763-1901
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-28
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY26429207QA0401X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4047817Medicaid
KY6426429400Medicaid
KY000000050365OtherANTHEM BCBS
TN1510590Medicaid
KY6426429400Medicaid
KY1897201Medicare PIN
TN4047817Medicaid