Provider Demographics
NPI:1427286939
Name:JADHAV, STEPHANIE NICHELLE (MD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:NICHELLE
Last Name:JADHAV
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:NICHELLE
Other - Last Name:GRAHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1401 HARRODSBURG RD
Mailing Address - Street 2:STE A510
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-3751
Mailing Address - Country:US
Mailing Address - Phone:859-258-6784
Mailing Address - Fax:859-258-6796
Practice Address - Street 1:1401 HARRODSBURG RD
Practice Address - Street 2:STE A510
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3751
Practice Address - Country:US
Practice Address - Phone:859-258-6784
Practice Address - Fax:859-258-6796
Is Sole Proprietor?:No
Enumeration Date:2009-06-24
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY46453207R00000X
WV24907207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0169Medicare PIN