Provider Demographics
NPI:1912974171
Name:GATEWOOD, DAMON L (MD)
Entity type:Individual
Prefix:
First Name:DAMON
Middle Name:L
Last Name:GATEWOOD
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 1:58 CITATION LANE
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40011-0460
Mailing Address - Country:US
Mailing Address - Phone:502-532-7341
Mailing Address - Fax:502-532-0127
Practice Address - Street 1:58 CITATION LANE
Practice Address - Street 2:
Practice Address - City:CAMPBELLSBURG
Practice Address - State:KY
Practice Address - Zip Code:40011-1426
Practice Address - Country:US
Practice Address - Phone:502-532-7341
Practice Address - Fax:502-532-0127
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2017-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY37028207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1165569OtherPASSPORT
KY2439968000OtherPASSPORT ADVANTAGE
KY64051949Medicaid
KY000000225634OtherANTHEM
KY0724601Medicare PIN
KYH67811Medicare UPIN
KY2439968000OtherPASSPORT ADVANTAGE