Provider Demographics
NPI:1063895613
Name:ABOU-JAOUDE, MICHELLE MARY (MD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARY
Last Name:ABOU-JAOUDE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 PERIMETER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-4121
Mailing Address - Country:US
Mailing Address - Phone:859-278-9393
Mailing Address - Fax:
Practice Address - Street 1:601 PERIMETER DR STE 200
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40517-4121
Practice Address - Country:US
Practice Address - Phone:859-278-9393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-01
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY52488207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100424310Medicaid
WV1063895613Medicaid
IN300025130Medicaid
OH0346494Medicaid