Provider Demographics
NPI:1821023250
Name:OUTSA, JUDY NONGLAK (DPM)
Entity Type:Individual
Prefix:DR
First Name:JUDY
Middle Name:NONGLAK
Last Name:OUTSA
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6407 PRESTON HWY
Mailing Address - Street 2:#1
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40219-1850
Mailing Address - Country:US
Mailing Address - Phone:502-409-5580
Mailing Address - Fax:502-409-5582
Practice Address - Street 1:6407 PRESTON HWY
Practice Address - Street 2:SUITE #1
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-1850
Practice Address - Country:US
Practice Address - Phone:502-409-5580
Practice Address - Fax:502-409-5582
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY244081213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100124330Medicaid
KY7100124330Medicaid