Provider Demographics
NPI:1326034901
Name:JOHN, GEORGE ROBERT (MD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:ROBERT
Last Name:JOHN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6400 DUTCHMANS PKWY STE 220A
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-3343
Mailing Address - Country:US
Mailing Address - Phone:502-894-9757
Mailing Address - Fax:502-894-9257
Practice Address - Street 1:6400 DUTCHMANS PKWY
Practice Address - Street 2:STE 220 A
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-3340
Practice Address - Country:US
Practice Address - Phone:502-894-9757
Practice Address - Fax:502-894-9257
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01044404207W00000X
KY29119207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1003129DMedicaid
KY64291198Medicaid
C75189Medicare UPIN
KY64291198Medicaid