Provider Demographics
NPI:1477795920
Name:FANNIN, KRISTOPHER ZEPHINAR (MD)
Entity Type:Individual
Prefix:
First Name:KRISTOPHER
Middle Name:ZEPHINAR
Last Name:FANNIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:3101 POPLAR LEVEL RD STE 101
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40213-1076
Practice Address - Country:US
Practice Address - Phone:502-636-7444
Practice Address - Fax:502-636-7112
Is Sole Proprietor?:No
Enumeration Date:2009-03-30
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR2574207Q00000X
390200000X
KY45200207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100138510Medicaid
IN201107020Medicaid
KYK054020Medicare PIN