Healthcare Provider Details

I. General information

NPI: 1326036385
Provider Name (Legal Business Name): JOHN A. DISTLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 02/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6400 WESTWIND WAY
CRESTWOOD KY
40014-6773
US

IV. Provider business mailing address

6400 WESTWIND WAY
CRESTWOOD KY
40014-6773
US

V. Phone/Fax

Practice location:
  • Phone: 502-243-2227
  • Fax: 502-243-2237
Mailing address:
  • Phone: 502-243-2227
  • Fax: 502-243-2237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberAD1776369
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number24245
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: