Provider Demographics
NPI:1003077934
Name:KUMMERFELDT FABIAN, CARLOS ENRIQUE (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:ENRIQUE
Last Name:KUMMERFELDT FABIAN
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 1:310 N L ROGERS WELLS BLVD
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-1300
Mailing Address - Country:US
Mailing Address - Phone:270-659-5835
Mailing Address - Fax:270-659-5856
Practice Address - Street 1:310 N L ROGERS WELLS BLVD
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-1300
Practice Address - Country:US
Practice Address - Phone:270-659-5835
Practice Address - Fax:270-659-5856
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-23
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY46647207RC0200X, 207RP1001X
FLTRN12138390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100301010Medicaid
KYK133141Medicare PIN