Provider Demographics
NPI:1417549098
Name:STOLLER, ALEX ZACHARY (MS, RDN)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:ZACHARY
Last Name:STOLLER
Suffix:
Gender:M
Credentials:MS, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 W LAKE COOK RD STE 160
Mailing Address - Street 2:
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-2091
Mailing Address - Country:US
Mailing Address - Phone:847-632-1880
Mailing Address - Fax:847-520-6095
Practice Address - Street 1:600 W LAKE COOK RD STE 160
Practice Address - Street 2:
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089-2091
Practice Address - Country:US
Practice Address - Phone:847-632-1880
Practice Address - Fax:847-520-6095
Is Sole Proprietor?:No
Enumeration Date:2021-02-05
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL164008317OtherSTATE LICENSE