Provider Demographics
NPI:1720193642
Name:MEMON, ABDUL M (MD)
Entity Type:Individual
Prefix:
First Name:ABDUL
Middle Name:M
Last Name:MEMON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4402 CHURCHMAN AVENUE
Mailing Address - Street 2:SUITE 305
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40215
Mailing Address - Country:US
Mailing Address - Phone:502-368-9590
Mailing Address - Fax:502-368-9616
Practice Address - Street 1:4402 CHURCHMAN AVENUE
Practice Address - Street 2:SUITE 305
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215
Practice Address - Country:US
Practice Address - Phone:502-368-9590
Practice Address - Fax:502-368-9616
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR8838207RC0200X, 207RP1001X
KY40505207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201413549Medicaid
000000511828OtherANTHEM
IN213320EOtherMEDICARE
KY1338510Medicare PIN
000000511828OtherANTHEM
MO003013696Medicare ID - Type Unspecified