Provider Demographics
NPI:1508859315
Name:GAYASADDIN, MOHAMMAD K (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:K
Last Name:GAYASADDIN
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 1:914 N DIXIE AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-2520
Mailing Address - Country:US
Mailing Address - Phone:270-765-2220
Mailing Address - Fax:270-765-2226
Practice Address - Street 1:914 N DIXIE AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2520
Practice Address - Country:US
Practice Address - Phone:270-765-2220
Practice Address - Fax:270-765-2226
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-26
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39269207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY6409216600Medicaid
KY6409216600Medicaid