Provider Demographics
NPI:1417482357
Name:MAMEDOV, BOKHODIR S
Entity Type:Individual
Prefix:
First Name:BOKHODIR
Middle Name:S
Last Name:MAMEDOV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3950 KRESGE WAY STE 308
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4637
Mailing Address - Country:US
Mailing Address - Phone:502-895-8911
Mailing Address - Fax:502-895-8977
Practice Address - Street 1:3950 KRESGE WAY STE 308
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4637
Practice Address - Country:US
Practice Address - Phone:502-851-3268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-28
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY54999207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program