Healthcare Provider Details

I. General information

NPI: 1962574897
Provider Name (Legal Business Name): DAMON GATEWOOD MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 06/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 CITATION LANE
CAMPBELLSBURG KY
40011-1426
US

IV. Provider business mailing address

58 CITATION LANE
CAMPBELLSBURG KY
40011-1426
US

V. Phone/Fax

Practice location:
  • Phone: 502-532-7341
  • Fax: 502-532-0127
Mailing address:
  • Phone: 502-532-7341
  • Fax: 502-532-0127

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number37028
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3007904
License Number StateKY

VIII. Authorized Official

Name: DR. DAMON L GATEWOOD
Title or Position: OWNER
Credential: MD
Phone: 502-532-7341