Provider Demographics
NPI:1194724229
Name:LAFFERTY, LON E (MD)
Entity type:Individual
Prefix:
First Name:LON
Middle Name:E
Last Name:LAFFERTY
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:PO BOX 1304
Mailing Address - Street 2:
Mailing Address - City:INEZ
Mailing Address - State:KY
Mailing Address - Zip Code:41224-1304
Mailing Address - Country:US
Mailing Address - Phone:606-298-7405
Mailing Address - Fax:606-298-3284
Practice Address - Street 1:2160 BLACKLOG RD
Practice Address - Street 2:
Practice Address - City:INEZ
Practice Address - State:KY
Practice Address - Zip Code:41224-9019
Practice Address - Country:US
Practice Address - Phone:606-295-5028
Practice Address - Fax:606-638-4502
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY24313207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64243132Medicaid
KY64243132Medicaid
KY00633001Medicare PIN
KY1425501Medicare PIN