Provider Demographics
NPI:1992992572
Name:LON LAFFERTY MD PSC
Entity type:Organization
Organization Name:LON LAFFERTY MD PSC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LON
Authorized Official - Middle Name:E
Authorized Official - Last Name:LAFFERTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-298-7405
Mailing Address - Street 1:PO BOX 1304
Mailing Address - Street 2:
Mailing Address - City:INEZ
Mailing Address - State:KY
Mailing Address - Zip Code:41224-1304
Mailing Address - Country:US
Mailing Address - Phone:606-298-4705
Mailing Address - Fax:606-298-3284
Practice Address - Street 1:RT 40 EAST BLACKLOG RD
Practice Address - Street 2:
Practice Address - City:INEZ
Practice Address - State:KY
Practice Address - Zip Code:41224
Practice Address - Country:US
Practice Address - Phone:606-298-7405
Practice Address - Fax:606-298-3284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-27
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY24313207QA0505X
261QR1300X
KY4341P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100043990Medicaid
KY7100043970Medicaid
KY=========OtherTAX ID
KY7100043970Medicaid
KY7100043990Medicaid