Provider Demographics
NPI:1881270684
Name:MERRELL, TREVOR (DO)
Entity type:Individual
Prefix:
First Name:TREVOR
Middle Name:
Last Name:MERRELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1679 N WILSON RD STE 105
Mailing Address - Street 2:
Mailing Address - City:RADCLIFF
Mailing Address - State:KY
Mailing Address - Zip Code:40160-1583
Mailing Address - Country:US
Mailing Address - Phone:270-272-0000
Mailing Address - Fax:270-352-2530
Practice Address - Street 1:1679 N WILSON RD STE 105
Practice Address - Street 2:
Practice Address - City:RADCLIFF
Practice Address - State:KY
Practice Address - Zip Code:40160-1583
Practice Address - Country:US
Practice Address - Phone:270-272-0000
Practice Address - Fax:270-352-2530
Is Sole Proprietor?:No
Enumeration Date:2021-03-22
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KYTP178207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program