Provider Demographics
NPI:1962402842
Name:ODONOGHUE, BRIAN T (MD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:T
Last Name:ODONOGHUE
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 1:107 OLD HIGHWAY 60
Mailing Address - Street 2:
Mailing Address - City:HARDINSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40143-2501
Mailing Address - Country:US
Mailing Address - Phone:270-580-2250
Mailing Address - Fax:
Practice Address - Street 1:107 OLD HIGHWAY 60
Practice Address - Street 2:
Practice Address - City:HARDINSBURG
Practice Address - State:KY
Practice Address - Zip Code:40143-2501
Practice Address - Country:US
Practice Address - Phone:270-580-2250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-21
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY32124207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000066552OtherANTHEM
KY65900656Medicaid
KY1072079OtherPASSPORT
KY65900656Medicaid
G31030Medicare UPIN