Provider Demographics
NPI:1194017384
Name:WILFONG, CHANDLER DONOVAN (MD)
Entity Type:Individual
Prefix:
First Name:CHANDLER
Middle Name:DONOVAN
Last Name:WILFONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12100 REDSPIRE DR
Mailing Address - Street 2:APT 204
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-6143
Mailing Address - Country:US
Mailing Address - Phone:502-432-2038
Mailing Address - Fax:
Practice Address - Street 1:12100 REDSPIRE DR
Practice Address - Street 2:APT 204
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-6143
Practice Address - Country:US
Practice Address - Phone:502-432-2038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-06
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY390200000X208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery