Provider Demographics
NPI:1639158207
Name:NIEDER, KATHY A (MD)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:A
Last Name:NIEDER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 950248
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0248
Mailing Address - Country:US
Mailing Address - Phone:502-489-5730
Mailing Address - Fax:502-489-5753
Practice Address - Street 1:1603 STEVENS AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-1087
Practice Address - Country:US
Practice Address - Phone:502-451-5955
Practice Address - Fax:502-451-5925
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY22083207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64220833Medicaid
KY000000500048OtherANTHEM
C69373Medicare UPIN
KY00162012Medicare PIN