Healthcare Provider Details

I. General information

NPI: 1588019707
Provider Name (Legal Business Name): ZACHARY D GILLOOLY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2016
Last Update Date: 09/21/2021
Certification Date: 09/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4881 SUGAR MAPLE DR
WPAFB OH
45433-5529
US

IV. Provider business mailing address

88 MDG/SGHJ 4881 SUGAR MAPLE DR
WPAFB OH
45433
US

V. Phone/Fax

Practice location:
  • Phone: 937-257-1574
  • Fax:
Mailing address:
  • Phone: 937-257-1574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberDR.0063949
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: