Provider Demographics
NPI:1689927576
Name:ASSOCIATE IN DERMATOLOGY AND DERMATOPATHOLOGY PLLC
Entity Type:Organization
Organization Name:ASSOCIATE IN DERMATOLOGY AND DERMATOPATHOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAFAYETTE
Authorized Official - Middle Name:G
Authorized Official - Last Name:OWEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-218-8927
Mailing Address - Street 1:1700 OLD BLUEGRASS AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40215-1174
Mailing Address - Country:US
Mailing Address - Phone:502-361-3909
Mailing Address - Fax:502-361-9229
Practice Address - Street 1:1700 OLD BLUEGRASS AVE STE 200
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215-1174
Practice Address - Country:US
Practice Address - Phone:502-361-3909
Practice Address - Fax:502-361-9229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-17
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY13257207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK066870Medicare PIN