Provider Demographics
NPI:1083145874
Name:MASSENGALE, TRAVIS (DO)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:MASSENGALE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 HOSPITAL WAY
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-2872
Mailing Address - Country:US
Mailing Address - Phone:606-451-2624
Mailing Address - Fax:
Practice Address - Street 1:350 HOSPITAL WAY
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-2872
Practice Address - Country:US
Practice Address - Phone:606-451-2624
Practice Address - Fax:606-451-5506
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-23
Last Update Date:2020-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY04599207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program