Provider Demographics
NPI:1710983093
Name:ALLEN, DAVID (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:ALLEN
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 1:2215 PORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40212-1033
Mailing Address - Country:US
Mailing Address - Phone:502-774-8631
Mailing Address - Fax:502-776-8912
Practice Address - Street 1:2215 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40212-1033
Practice Address - Country:US
Practice Address - Phone:502-774-8631
Practice Address - Fax:502-776-8912
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY20963207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY50001609OtherPASSPORT PORTLAND
KY64209638Medicaid
KY50001612OtherPASSPORT IQ
KY50001610OtherPASSPORT FD
KY50001926OtherPASSPORT ZE
KY50001611OtherPASSPORT EB
KY50001614OtherPASSPORT PX
KY000000321461OtherANTHEM
KY0795601Medicare ID - Type UnspecifiedDIXIE
KY50001926OtherPASSPORT ZE
KY50001609OtherPASSPORT PORTLAND
KY50001611OtherPASSPORT EB
KY0538757Medicare ID - Type UnspecifiedPHOENIX
KY0538658Medicare ID - Type UnspecifiedIROQUOIS
KY000000321461OtherANTHEM