Provider Demographics
NPI:1053347120
Name:ZELLMER, JOHNNY A (MD)
Entity type:Individual
Prefix:DR
First Name:JOHNNY
Middle Name:A
Last Name:ZELLMER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 E CLARK BASS BLVD
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501-4209
Mailing Address - Country:US
Mailing Address - Phone:918-426-1800
Mailing Address - Fax:918-421-8066
Practice Address - Street 1:3101 ELKS ROAD
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501
Practice Address - Country:US
Practice Address - Phone:918-426-2442
Practice Address - Fax:918-426-0888
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK20237207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100228090AMedicaid
OKM003401027Medicare ID - Type Unspecified
OKG54193Medicare UPIN