Provider Demographics
NPI:1285610535
Name:WEBB, ELLEN DIVAS (MD)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:DIVAS
Last Name:WEBB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:220 FRANKFORT ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:VERSAILLES
Mailing Address - State:KY
Mailing Address - Zip Code:40383-1079
Mailing Address - Country:US
Mailing Address - Phone:859-873-0905
Mailing Address - Fax:859-873-1025
Practice Address - Street 1:220 FRANKFORT ST
Practice Address - Street 2:SUITE 2
Practice Address - City:VERSAILLES
Practice Address - State:KY
Practice Address - Zip Code:40383
Practice Address - Country:US
Practice Address - Phone:859-873-0905
Practice Address - Fax:859-873-1025
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY24998207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0905208Medicaid
KY64001340Medicaid
KY00630Medicare PIN
C69208Medicare UPIN
KY0905208Medicaid