Provider Demographics
NPI:1700014917
Name:NALL, MICHAEL SANFORD (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SANFORD
Last Name:NALL
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 1:9113 LEESGATE RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-5003
Mailing Address - Country:US
Mailing Address - Phone:502-426-1621
Mailing Address - Fax:502-426-7906
Practice Address - Street 1:9113 LEESGATE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-5003
Practice Address - Country:US
Practice Address - Phone:502-426-1621
Practice Address - Fax:502-426-7906
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY14272207K00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY50025708OtherPASSPORT
KY14272OtherKY LICENSE
KY4012731OtherAETNA
KY64142722Medicaid
KY0225915Medicare PIN
KY4012731OtherAETNA