Healthcare Provider Details

I. General information

NPI: 1902101199
Provider Name (Legal Business Name): COMMONWEALTH NEUROLOGY & SLEEP CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2011
Last Update Date: 07/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

439 W WALNUT ST SUITE 201
DANVILLE KY
40422-1877
US

IV. Provider business mailing address

PO BOX 2485
DANVILLE KY
40423-2485
US

V. Phone/Fax

Practice location:
  • Phone: 859-236-5366
  • Fax: 859-236-6754
Mailing address:
  • Phone: 859-236-5366
  • Fax: 859-236-6754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number42286
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number42286
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number42286
License Number StateKY

VIII. Authorized Official

Name: DR. DEEPA NIDHIRY
Title or Position: PRESIDENT
Credential: MD
Phone: 859-236-5366