Provider Demographics
NPI:1265446256
Name:PEENO, DOUGLAS OWEN (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:OWEN
Last Name:PEENO
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 1:2700 STANLEY GAULT PKWY
Mailing Address - Street 2:STE 129
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5176
Mailing Address - Country:US
Mailing Address - Phone:502-253-4917
Mailing Address - Fax:502-489-5751
Practice Address - Street 1:3999 DUTCHMANS LN
Practice Address - Street 2:SUITE 4D
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4729
Practice Address - Country:US
Practice Address - Phone:502-893-6777
Practice Address - Fax:502-899-5535
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY19315207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY2623OtherBLUE CROSS
KY1051305OtherPASSPORT
KY64193154Medicaid
KY64193154Medicaid
KYK006160Medicare Oscar/Certification
KYP00957737Medicare PIN
KY2623OtherBLUE CROSS