Provider Demographics
NPI:1437177797
Name:ALLEN, LETICIA KATHRYN (MD)
Entity Type:Individual
Prefix:
First Name:LETICIA
Middle Name:KATHRYN
Last Name:ALLEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 E LIBERTY ST STE 800
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1428
Mailing Address - Country:US
Mailing Address - Phone:502-633-4622
Mailing Address - Fax:502-633-6925
Practice Address - Street 1:60 MACK WALTERS RD
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40065-1738
Practice Address - Country:US
Practice Address - Phone:502-633-4622
Practice Address - Fax:502-633-6925
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY37109207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000226036OtherBLUE CROSS NUMBER
KY64050362Medicaid
KY64050362OtherKEN PAC NUMBER
KY0720501Medicare PIN
KY000000226036OtherBLUE CROSS NUMBER
KYK147350 (KOHMG)Medicare PIN
KYP01535778 RR (KOHMG)Medicare PIN