Basic Information
| Provider Information | |||||||||
| NPI: | 1194708776 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ZOELLER | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2413 RING RD STE 110 | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427015924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707654535 | ||||||||
| FaxNumber: | 2707631901 | ||||||||
| Practice Location | |||||||||
| Address1: | 2413 RING RD STE 110 | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427015924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707654535 | ||||||||
| FaxNumber: | 2707631901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2005 | ||||||||
| LastUpdateDate: | 02/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 26429 | KY | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QA0401X | 26429 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4047817 | 05 | TN | MEDICAID | 000000050365 | 01 | KY | ANTHEM BCBS | OTHER | 1510590 | 05 | TN | MEDICAID | 6426429400 | 05 | KY | MEDICAID |