Provider Demographics
NPI:1396743258
Name:SUTTON-DAVIS, LESA SUE (MD)
Entity type:Individual
Prefix:DR
First Name:LESA
Middle Name:SUE
Last Name:SUTTON-DAVIS
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 638706
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-8706
Mailing Address - Country:US
Mailing Address - Phone:270-827-7558
Mailing Address - Fax:270-827-7530
Practice Address - Street 1:2000 N ELM ST STE 1B
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-2385
Practice Address - Country:US
Practice Address - Phone:270-844-8144
Practice Address - Fax:270-844-8145
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36607208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000910700OtherANTHEM - NCMA
KY170480OtherSIHO-NCMA
KY50086973OtherPASSPORT - NCMA FAIRDALE
KY50086969OtherPASSPORT - NCMA BRECKENRIDGE
KY64027493Medicaid
KYK178190Medicare PIN
KYP400034000Medicare PIN
KYP400033999Medicare PIN