Provider Demographics
NPI:1669708020
Name:KUZNETSOV, SOFYA (MD)
Entity type:Individual
Prefix:
First Name:SOFYA
Middle Name:
Last Name:KUZNETSOV
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:502-272-5337
Mailing Address - Fax:502-272-5339
Practice Address - Street 1:6420 DUTCHMANS PKWY STE 200
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-3373
Practice Address - Country:US
Practice Address - Phone:502-891-8300
Practice Address - Fax:502-891-8388
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-20
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.057550207R00000X
KY51423207R00000X, 207RC0000X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100539310Medicaid
IN300017096Medicaid