Provider Demographics
NPI:1346399318
Name:GAGER, PETER JUDSON (PHD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:JUDSON
Last Name:GAGER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:PETER
Other - Middle Name:JUDSON
Other - Last Name:GAGER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:3175 CUSTER DR STE 302B
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-4023
Mailing Address - Country:US
Mailing Address - Phone:859-533-9190
Mailing Address - Fax:
Practice Address - Street 1:3175 CUSTER DR STE 302B
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40517-4023
Practice Address - Country:US
Practice Address - Phone:859-533-9190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY165460103G00000X
KY00222189103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
V55621Medicare PIN