Provider Demographics
NPI:1962821447
Name:PETTIBONE, ZACHARY
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:
Last Name:PETTIBONE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4075 OLD WESTERN ROW RD
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-3104
Mailing Address - Country:US
Mailing Address - Phone:513-536-0246
Mailing Address - Fax:513-536-0159
Practice Address - Street 1:4075 OLD WESTERN ROW RD
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040
Practice Address - Country:US
Practice Address - Phone:513-536-4673
Practice Address - Fax:513-536-0159
Is Sole Proprietor?:No
Enumeration Date:2014-04-10
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.1324572084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry