Provider Demographics
NPI:1700863230
Name:DISTLER, DANA J (MD)
Entity Type:Individual
Prefix:DR
First Name:DANA
Middle Name:J
Last Name:DISTLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:DANA
Other - Middle Name:J
Other - Last Name:LYONS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD,
Mailing Address - Street 1:301 MIDDLETOWN PARK PL
Mailing Address - Street 2:SUITE C
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40243-2515
Mailing Address - Country:US
Mailing Address - Phone:502-244-9858
Mailing Address - Fax:
Practice Address - Street 1:301 MIDDLETOWN PARK PL
Practice Address - Street 2:SUITE C
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40243-2515
Practice Address - Country:US
Practice Address - Phone:502-244-9858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY288832080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYG14634Medicare UPIN