Provider Demographics
NPI:1578706289
Name:TREESE, DAVID TYLER (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:TYLER
Last Name:TREESE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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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 1:7430 JEFFERSON BLVD
Practice Address - Street 2:STE 200
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-6159
Practice Address - Country:US
Practice Address - Phone:502-968-3010
Practice Address - Fax:502-968-0035
Is Sole Proprietor?:No
Enumeration Date:2009-04-10
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY45645207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100132910Medicaid
KY138687OtherSIHO - NCMA
KY138687OtherSIHO - NMA
KY50043205OtherPASSPORT - NMA
KY50043207OtherPASSPORT - NCMA
KY000000781114OtherANTHEM - NCMA
KY000000783923OtherANTHEM - NMA
KY000000781114OtherANTHEM - NCMA