Provider Demographics
NPI:1720048093
Name:CONNER, DOUGLAS ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:ALLEN
Last Name:CONNER
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 1:413 S LOOP RD
Mailing Address - Street 2:ST ELIZABETH FAMILY PRACTICE CENTER
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-5446
Mailing Address - Country:US
Mailing Address - Phone:859-301-3800
Mailing Address - Fax:859-301-3987
Practice Address - Street 1:413 S LOOP RD
Practice Address - Street 2:ST ELIZABETH FAMILY PRACTICE CENTER
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-5446
Practice Address - Country:US
Practice Address - Phone:859-301-3800
Practice Address - Fax:859-301-3987
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY28181207Q00000X, 207Q00000X
IN01067451A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2213661Medicaid
KY7100439330Medicaid
IN200407600Medicaid
F52825Medicare UPIN
OH2213661Medicaid
KY7100439330Medicaid
IN200407600Medicaid
KY3313273Medicare PIN