Provider Demographics
NPI:1215738612
Name:BOTHE, DONALD SAMUEL THOMAS
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:SAMUEL THOMAS
Last Name:BOTHE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:DONALD
Other - Middle Name:S
Other - Last Name:BOTHE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8611 MCKENNA WAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40291-2756
Mailing Address - Country:US
Mailing Address - Phone:502-528-3413
Mailing Address - Fax:
Practice Address - Street 1:780 ROSE ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-0001
Practice Address - Country:US
Practice Address - Phone:859-323-6161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-21
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program