Provider Demographics
NPI:1467403139
Name:BOUVETTE, MICHAEL J (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:BOUVETTE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6801 DIXIE HWY
Mailing Address - Street 2:SUITE 130
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40258-3913
Mailing Address - Country:US
Mailing Address - Phone:502-587-4404
Mailing Address - Fax:502-587-4155
Practice Address - Street 1:200 ABRAHAM FLEXNER WAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1818
Practice Address - Country:US
Practice Address - Phone:502-587-4404
Practice Address - Fax:502-587-4155
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2010-11-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KY33337207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200255010AMedicaid
KY64009483Medicaid
KY64009483Medicaid
KY00546042Medicare Oscar/Certification
KYG85516Medicare UPIN