Provider Demographics
NPI:1326095969
Name:ETTIN, DOUGLAS S (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:S
Last Name:ETTIN
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:PO BOX 6749
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40206-0749
Mailing Address - Country:US
Mailing Address - Phone:502-899-7646
Mailing Address - Fax:502-899-7648
Practice Address - Street 1:4000 KRESGE WAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4605
Practice Address - Country:US
Practice Address - Phone:502-899-7646
Practice Address - Fax:502-899-7648
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34883207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200226960Medicaid
KY64012388Medicaid
KY34883OtherKENTUCKY LICENSE
KYBE4978928OtherDEA
KY64012388Medicaid
KY0574149Medicare PIN
IN200226960Medicaid