Provider Demographics
NPI:1811950256
Name:SUETHOLZ, DAVID WAYNE (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:WAYNE
Last Name:SUETHOLZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2378 GRANDVIEW DR
Mailing Address - Street 2:
Mailing Address - City:FORT MITCHELL
Mailing Address - State:KY
Mailing Address - Zip Code:41017-1633
Mailing Address - Country:US
Mailing Address - Phone:859-341-1122
Mailing Address - Fax:859-341-1171
Practice Address - Street 1:2378 GRANDVIEW DR
Practice Address - Street 2:
Practice Address - City:FORT MITCHELL
Practice Address - State:KY
Practice Address - Zip Code:41017-1633
Practice Address - Country:US
Practice Address - Phone:859-341-1122
Practice Address - Fax:859-341-1171
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-07
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY18013207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64180136Medicaid
OH0280360Medicaid
OH0280360Medicaid
KY0364956Medicare PIN
KYC70944Medicare UPIN