Provider Demographics
NPI:1083679880
Name:LAGERSTROM, REX P (MD)
Entity type:Individual
Prefix:
First Name:REX
Middle Name:P
Last Name:LAGERSTROM
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 1:2700 STANLEY GAULT PKWY STE 129
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5176
Mailing Address - Country:US
Mailing Address - Phone:502-253-4900
Mailing Address - Fax:502-489-5750
Practice Address - Street 1:4003 KRESGE WAY STE 410
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4652
Practice Address - Country:US
Practice Address - Phone:502-893-7462
Practice Address - Fax:502-212-7550
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY24848207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64248487Medicaid
KYK144350Medicare UPIN
KY00546136Medicare Oscar/Certification
KY64248487Medicaid
KYP00401701Medicare PIN