Provider Demographics
NPI:1962567511
Name:NORTHENOR, DENNIS (OD)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:
Last Name:NORTHENOR
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3563 SPRINGHURST BLVD.
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241
Mailing Address - Country:US
Mailing Address - Phone:502-339-7323
Mailing Address - Fax:502-412-7331
Practice Address - Street 1:3563 SPRINGHURST BLVD.
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241
Practice Address - Country:US
Practice Address - Phone:502-339-7323
Practice Address - Fax:502-412-7331
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0821DT152W00000X
KY821DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77008217Medicaid
KY77008217Medicaid
KY9365901Medicare ID - Type UnspecifiedOD PIN