Provider Demographics
NPI:1013930361
Name:MOTTLEY, DOUGLAS M (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:M
Last Name:MOTTLEY
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 1:2201 LEXINGTON AVE
Mailing Address - Street 2:SUITE 8B
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101-2843
Mailing Address - Country:US
Mailing Address - Phone:606-327-5190
Mailing Address - Fax:606-327-6693
Practice Address - Street 1:2201 LEXINGTON AVE
Practice Address - Street 2:SUITE 8B
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-2843
Practice Address - Country:US
Practice Address - Phone:606-327-5190
Practice Address - Fax:606-327-6693
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTP680174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY40409OtherLICENSE
KYI63748Medicare UPIN