Provider Demographics
NPI:1477642270
Name:DURRETT, RONALD LEE (CPO)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:LEE
Last Name:DURRETT
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 MEDICAL VILLAGE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-5401
Mailing Address - Country:US
Mailing Address - Phone:859-341-7688
Mailing Address - Fax:859-341-4476
Practice Address - Street 1:525 ALEXANDRIA PIKE
Practice Address - Street 2:SUITE 250
Practice Address - City:SOUTHGATE
Practice Address - State:KY
Practice Address - Zip Code:41071-3290
Practice Address - Country:US
Practice Address - Phone:859-441-8111
Practice Address - Fax:859-441-8111
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY21755OtherABP-SG
KY0680460002Medicare ID - Type UnspecifiedSOUTHGATE MEDICARE #