Provider Demographics
NPI:1093138323
Name:OWENSBORO DERMATOLOGY ASSOCIATES
Entity Type:Organization
Organization Name:OWENSBORO DERMATOLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:JUNE
Authorized Official - Middle Name:D
Authorized Official - Last Name:CONDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-685-5777
Mailing Address - Street 1:2821 NEW HARTFORD RD
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-1320
Mailing Address - Country:US
Mailing Address - Phone:270-685-5777
Mailing Address - Fax:270-685-0190
Practice Address - Street 1:2821 NEW HARTFORD RD
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-1320
Practice Address - Country:US
Practice Address - Phone:270-685-5777
Practice Address - Fax:270-685-0190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-22
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTP512207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3956Medicare PIN