Healthcare Provider Details

I. General information

NPI: 1720048093
Provider Name (Legal Business Name): DOUGLAS ALLEN CONNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 03/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 S LOOP RD ST ELIZABETH FAMILY PRACTICE CENTER
EDGEWOOD KY
41017-5446
US

IV. Provider business mailing address

413 S LOOP RD ST ELIZABETH FAMILY PRACTICE CENTER
EDGEWOOD KY
41017-5446
US

V. Phone/Fax

Practice location:
  • Phone: 859-301-3800
  • Fax: 859-301-3987
Mailing address:
  • Phone: 859-301-3800
  • Fax: 859-301-3987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number28181
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01067451A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: