Provider Demographics
NPI:1245791284
Name:GHERNAUTAN, VICTORIA (MD)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:GHERNAUTAN
Suffix:
Gender:F
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:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:210 E GRAY ST STE 605
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3900
Practice Address - Country:US
Practice Address - Phone:502-559-3636
Practice Address - Fax:502-629-5442
Is Sole Proprietor?:No
Enumeration Date:2019-03-30
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY59295207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program