Provider Demographics
NPI:1134461528
Name:CONDON, HEATHER L (MD)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:L
Last Name:CONDON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:L
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2816 VEACH RD
Mailing Address - Street 2:SUITE 403
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-6295
Mailing Address - Country:US
Mailing Address - Phone:270-684-1145
Mailing Address - Fax:
Practice Address - Street 1:811 E PARRISH AVE STE 101
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-3258
Practice Address - Country:US
Practice Address - Phone:270-691-8040
Practice Address - Fax:270-691-8049
Is Sole Proprietor?:No
Enumeration Date:2013-03-23
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY49389207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100411540Medicaid
IN201388030Medicaid
IN201388030Medicaid