Provider Demographics
NPI:1790839819
Name:OTREMBIAK, JAMES JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:JOHN
Last Name:OTREMBIAK
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 1:525 ALEXANDRIA PIKE STE 320
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:KY
Mailing Address - Zip Code:41071-3243
Mailing Address - Country:US
Mailing Address - Phone:859-781-1310
Mailing Address - Fax:859-572-3021
Practice Address - Street 1:525 ALEXANDRIA PIKE STE 320
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:KY
Practice Address - Zip Code:41071
Practice Address - Country:US
Practice Address - Phone:859-781-1310
Practice Address - Fax:859-572-3021
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
KY22676208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64226764Medicaid
KY64226764Medicaid
KYF52311Medicare UPIN