Provider Demographics
NPI:1558369546
Name:PRIDHAM, DWIGHT (MD)
Entity Type:Individual
Prefix:DR
First Name:DWIGHT
Middle Name:
Last Name:PRIDHAM
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:502-272-5339
Practice Address - Street 1:4123 DUTCHMANS LN
Practice Address - Street 2:SUITE 300
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207
Practice Address - Country:US
Practice Address - Phone:502-899-6755
Practice Address - Fax:502-899-6753
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY25165207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK024740OtherMEDICARE PTAN- WOMEN'S SPECIALISTS
KY64251655Medicaid
C66550Medicare UPIN
C66550Medicare UPIN
KYK024740OtherMEDICARE PTAN- WOMEN'S SPECIALISTS
0386310Medicare ID - Type Unspecified