Healthcare Provider Details

I. General information

NPI: 1861782849
Provider Name (Legal Business Name): ZACHARY MYLES NOLLIN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2011
Last Update Date: 05/28/2020
Certification Date: 05/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 N PORTLAND AVE STE 600
OKLAHOMA CITY OK
73112-2121
US

IV. Provider business mailing address

5300 N INDEPENDENCE AVE STE 280
OKLAHOMA CITY OK
73112-5555
US

V. Phone/Fax

Practice location:
  • Phone: 405-713-9940
  • Fax: 405-713-9941
Mailing address:
  • Phone: 405-713-9940
  • Fax: 405-713-9941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number5257
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: