Provider Demographics
NPI:1346493400
Name:EKSTROM, KATHRYN MARIE (MD)
Entity Type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:MARIE
Last Name:EKSTROM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:KATHRYN
Other - Middle Name:MARIE
Other - Last Name:PIERCY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1510
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47706-1510
Mailing Address - Country:US
Mailing Address - Phone:812-450-6879
Mailing Address - Fax:270-389-3707
Practice Address - Street 1:1300 MERRITT DR STE 100
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-2788
Practice Address - Country:US
Practice Address - Phone:270-827-0064
Practice Address - Fax:270-826-3338
Is Sole Proprietor?:No
Enumeration Date:2008-11-02
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7471451-1205207R00000X, 208000000X
KY47919208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100345240Medicaid
KYK187600Medicare PIN