Provider Demographics
NPI:1902803091
Name:DENNISON, JOSEPH RANDALL (MD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:RANDALL
Last Name:DENNISON
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 1:991 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:MAYSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41056-8764
Mailing Address - Country:US
Mailing Address - Phone:606-759-9050
Mailing Address - Fax:606-759-4407
Practice Address - Street 1:991 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:MAYSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41056-8764
Practice Address - Country:US
Practice Address - Phone:606-759-9050
Practice Address - Fax:606-759-4407
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY22358174400000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64223589Medicaid
KYD32287Medicare UPIN
KY1355101Medicare ID - Type Unspecified