Basic Information
| Provider Information | |||||||||
| NPI: | 1790904019 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ZOLLETT | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1530 NEEDMORE RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454143969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373962602 | ||||||||
| FaxNumber: | 9373953682 | ||||||||
| Practice Location | |||||||||
| Address1: | 1530 NEEDMORE RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454143969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373962602 | ||||||||
| FaxNumber: | 9373953682 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2007 | ||||||||
| LastUpdateDate: | 05/15/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 34.008249 | OH | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 2457443 | 05 | OH | MEDICAID |