Provider Demographics
NPI:1558592527
Name:VYLETA, MARTIN S (MD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:S
Last Name:VYLETA
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Gender:M
Credentials:MD
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Mailing Address - Street 1:530 S JACKSON ST
Mailing Address - Street 2:SUITE C07
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1675
Mailing Address - Country:US
Mailing Address - Phone:502-852-5875
Mailing Address - Fax:502-852-1754
Practice Address - Street 1:530 S JACKSON ST
Practice Address - Street 2:SUITE C07
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1675
Practice Address - Country:US
Practice Address - Phone:502-852-5875
Practice Address - Fax:502-852-1754
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-07
Last Update Date:2021-07-13
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Provider Licenses
StateLicense IDTaxonomies
KYFL0292085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100084730Medicaid