1396743258 NPI number — DR. LESA SUE SUTTON-DAVIS M.D.

Table of content: DR. LESA SUE SUTTON-DAVIS M.D. (NPI 1396743258)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396743258 NPI number — DR. LESA SUE SUTTON-DAVIS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUTTON-DAVIS
Provider First Name:
LESA
Provider Middle Name:
SUE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396743258
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 638706
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45263-8706
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-827-7558
Provider Business Mailing Address Fax Number:
270-827-7530

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2000 N ELM ST STE 1B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HENDERSON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42420-2385
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-844-8144
Provider Business Practice Location Address Fax Number:
270-844-8145
Provider Enumeration Date:
07/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  36607 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000910700 . This is a "ANTHEM - NCMA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 170480 . This is a "SIHO-NCMA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 50086973 . This is a "PASSPORT - NCMA FAIRDALE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 50086969 . This is a "PASSPORT - NCMA BRECKENRIDGE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 64027493 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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