Provider Demographics
NPI:1124741780
Name:CENTRAL KENTUCKY DERMATOLOGY PLLC
Entity type:Organization
Organization Name:CENTRAL KENTUCKY DERMATOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-608-9917
Mailing Address - Street 1:231 E BRANNON RD
Mailing Address - Street 2:
Mailing Address - City:NICHOLASVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40356-8059
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:231 E BRANNON RD STE 249
Practice Address - Street 2:
Practice Address - City:NICHOLASVILLE
Practice Address - State:KY
Practice Address - Zip Code:40356-8059
Practice Address - Country:US
Practice Address - Phone:859-354-5455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-20
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty