Healthcare Provider Details

I. General information

NPI: 1609036375
Provider Name (Legal Business Name): CHRISTOPHER ZIETLOW MD PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2008
Last Update Date: 07/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 HADLEY RD
MOORESVILLE IN
46158-1737
US

IV. Provider business mailing address

1155 W JEFFERSON ST STE 104
FRANKLIN IN
46131-2731
US

V. Phone/Fax

Practice location:
  • Phone: 317-834-3263
  • Fax: 317-834-5194
Mailing address:
  • Phone: 317-834-3263
  • Fax: 317-834-5194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35-090815
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number01065671A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: