Provider Demographics
NPI:1982611257
Name:LOUISSE, MARCO CORNELIS (MD)
Entity Type:Individual
Prefix:DR
First Name:MARCO
Middle Name:CORNELIS
Last Name:LOUISSE
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: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:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:7926 PRESTON HWY STE 106
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-3848
Practice Address - Country:US
Practice Address - Phone:502-964-4357
Practice Address - Fax:502-966-5948
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00041159207Q00000X
KY42180207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP00378656OtherRAILROAD MEDICARE
KY7100270690Medicaid
KY000000590540OtherANTHEM
WA8313868Medicaid
INP00737020OtherRAILROAD MEDICARE
KYP00817257OtherRAILROAD MEDICARE
IN201000050Medicaid
WA8313868Medicaid
KY000000590540OtherANTHEM
KYP00817257OtherRAILROAD MEDICARE
WAH67785Medicare UPIN