Provider Demographics
NPI:1396969200
Name:MCMAHAN, CRYSTAL HAMILTON (MD)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:HAMILTON
Last Name:MCMAHAN
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 950248
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0248
Mailing Address - Country:US
Mailing Address - Phone:502-489-5730
Mailing Address - Fax:502-489-5753
Practice Address - Street 1:4003 KRESGE WAY
Practice Address - Street 2:STE 115
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4652
Practice Address - Country:US
Practice Address - Phone:502-897-8163
Practice Address - Fax:502-897-8052
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY422032085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY50027952OtherPASSPORT
KY7100059430Medicaid
KY000000651185OtherANTHEM
KY50027952OtherPASSPORT