Provider Demographics
NPI:1972504819
Name:MEREDITH, CONNIE (MD)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:MEREDITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:M
Other - Last Name:BAUER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4004 DUPONT CIR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4819
Mailing Address - Country:US
Mailing Address - Phone:502-897-1604
Mailing Address - Fax:502-897-0489
Practice Address - Street 1:4004 DUPONT CIR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4819
Practice Address - Country:US
Practice Address - Phone:502-897-1604
Practice Address - Fax:502-897-0489
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY35148207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64050164Medicaid
KYK120511Medicare PIN
H63938Medicare UPIN
KYP0156561Medicare PIN