Provider Demographics
NPI:1073523056
Name:ZETTLER, EDWINA RANDALL (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWINA
Middle Name:RANDALL
Last Name:ZETTLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6259 CASEY CT
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-3694
Mailing Address - Country:US
Mailing Address - Phone:513-829-7677
Mailing Address - Fax:
Practice Address - Street 1:2449 ROSS MILLVILLE RD
Practice Address - Street 2:ROSS MEDICAL CENTER, SUITE 252
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45013-8951
Practice Address - Country:US
Practice Address - Phone:888-958-5830
Practice Address - Fax:888-433-6146
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2017-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY393402084P0800X
OH35.0910842084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0331323Medicare ID - Type UnspecifiedMEDICARE
KY0406215Medicare ID - Type UnspecifiedMEDICARE
KYI39574Medicare UPIN
KYI39574Medicare UPIN