Provider Demographics
NPI:1083601553
Name:BLAND, VIVIAN H (MD)
Entity Type:Individual
Prefix:MRS
First Name:VIVIAN
Middle Name:H
Last Name:BLAND
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:914 N DIXIE AVE
Mailing Address - Street 2:SUITE 306
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-2537
Mailing Address - Country:US
Mailing Address - Phone:270-769-1559
Mailing Address - Fax:270-234-9152
Practice Address - Street 1:914 N DIXIE AVE
Practice Address - Street 2:SUITE 306
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2537
Practice Address - Country:US
Practice Address - Phone:270-769-1559
Practice Address - Fax:270-234-9152
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY17393207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000062513OtherANTHEM PROVIDER
KY64173933Medicaid
KY0693201Medicare ID - Type Unspecified
KY000000062513OtherANTHEM PROVIDER
KY64173933Medicaid