Provider Demographics
NPI:1144394206
Name:POPOVICH, PETER J (DO)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:J
Last Name:POPOVICH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 950112
Mailing Address - Street 2:DEPT. 52387
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0112
Mailing Address - Country:US
Mailing Address - Phone:866-965-3774
Mailing Address - Fax:781-276-6411
Practice Address - Street 1:913 N DIXIE AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2503
Practice Address - Country:US
Practice Address - Phone:877-783-6257
Practice Address - Fax:859-514-5521
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM5446207P00000X
KY03164207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00650256OtherRAILROAD
TX188382902Medicaid
TX8AA314OtherBCBS
TX8W1785OtherBCBS
TX8W1785OtherBCBS
MOF91129Medicare UPIN
KY0694548Medicare PIN