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Provider Information for 1992167902

Please Note: Issuance of an NPI does not ensure or validate that the Health Care Provider is Licensed or Credentialed. For more information please refer to NPI: What You Need to Know


Gender: MALE

Individual NPI: 1992167902

Calendar   Last Updated:  2019-07-02
  Certification Date: 


Name Value
NPI 1992167902
Enumeration Date 2016-03-28
NPI Type 1 - Individual
Sole Proprietor YES
Status Active
Mailing Address 734 W MAIN ST STE 106
LOUISVILLE, KY 40202-3622
United States

Phone: 502-804-4811 | Fax:
View Map External Link
Primary Practice Address 2818 GRANT LINE RD
NEW ALBANY, IN 47150-2492
United States

Phone: 812-725-7542 | Fax:
View Map External Link
Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
Primary Taxonomy Selected Taxonomy State License Number
Yes 213ES0103X - Podiatrist Foot & Ankle Surgery IN 07001304A
No 213ES0103X - Podiatrist Foot & Ankle Surgery KY 246411