Provider Demographics
NPI:1104975051
Name:TACKETT, LADDIE L (MD)
Entity type:Individual
Prefix:DR
First Name:LADDIE
Middle Name:L
Last Name:TACKETT
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Gender:M
Credentials:MD
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Mailing Address - Street 1:13550 TRITON PARK BLVD FL 4
Mailing Address - Street 2:ANTHEM BLUE CROSS AND BLUE SHIELD
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-4194
Mailing Address - Country:US
Mailing Address - Phone:502-889-2711
Mailing Address - Fax:502-889-2783
Practice Address - Street 1:13550 TRITON PARK BLVD FL 4
Practice Address - Street 2:ANTHEM BLUE CROSS AND BLUE SHIELD
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-4194
Practice Address - Country:US
Practice Address - Phone:502-889-2711
Practice Address - Fax:502-889-2783
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
KY19626208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery