Provider Demographics
NPI:1528128667
Name:JUDITH A ZELLERS OD PA
Entity type:Organization
Organization Name:JUDITH A ZELLERS OD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:ZELLERS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:239-947-6000
Mailing Address - Street 1:3925 BONITA BEACH RD
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134-4112
Mailing Address - Country:US
Mailing Address - Phone:239-947-6000
Mailing Address - Fax:239-947-3914
Practice Address - Street 1:3925 BONITA BEACH RD
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-4112
Practice Address - Country:US
Practice Address - Phone:239-947-6000
Practice Address - Fax:239-947-3914
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1708152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOPC1708OtherSTATE LICENSE
FL078433800Medicaid
FLOPC1708OtherSTATE LICENSE
19364Medicare ID - Type Unspecified