Provider Demographics
NPI:1588019707
Name:GILLOOLY, ZACHARY D (MD)
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:D
Last Name:GILLOOLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 MDG/SGHJ
Mailing Address - Street 2:4881 SUGAR MAPLE DR
Mailing Address - City:WPAFB
Mailing Address - State:OH
Mailing Address - Zip Code:45433
Mailing Address - Country:US
Mailing Address - Phone:937-257-1574
Mailing Address - Fax:
Practice Address - Street 1:4881 SUGAR MAPLE DR
Practice Address - Street 2:
Practice Address - City:WPAFB
Practice Address - State:OH
Practice Address - Zip Code:45433-5529
Practice Address - Country:US
Practice Address - Phone:937-257-1574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-25
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0063949207N00000X, 207N00000X
TX390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program