Provider Demographics
NPI:1417931957
Name:POPHAM, TIMOTHY B (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:B
Last Name:POPHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1169 EASTERN PKWY
Mailing Address - Street 2:G58
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40217
Mailing Address - Country:US
Mailing Address - Phone:502-452-9567
Mailing Address - Fax:502-473-0586
Practice Address - Street 1:1169 EASTERN PKWY
Practice Address - Street 2:G58
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217
Practice Address - Country:US
Practice Address - Phone:502-452-9567
Practice Address - Fax:502-473-0586
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-29
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY21233207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64212335Medicaid
KY1049205OtherPASSPORT
A83500Medicare UPIN
KY1505301Medicare ID - Type Unspecified