Provider Demographics
NPI:1710984273
Name:ODER, KENNETH LEE (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:LEE
Last Name:ODER
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:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:12615 TAYLORSVILLE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-4452
Practice Address - Country:US
Practice Address - Phone:502-261-1595
Practice Address - Fax:502-261-1590
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY25195207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64251952Medicaid
KY64251952Medicaid
1909101Medicare ID - Type Unspecified
P400025206Medicare PIN