Healthcare Provider Details

I. General information

NPI: 1770569352
Provider Name (Legal Business Name): THOMAS ROBERT HUSTEAD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 10/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2413 RING RD STE 100
ELIZABETHTOWN KY
42701-5924
US

IV. Provider business mailing address

1 JARRETT WHITE RD DEPARTMENT OF FAMILY MEDICINE
TRIPLER ARMY MEDICAL CENTER HI
96859-5000
US

V. Phone/Fax

Practice location:
  • Phone: 270-737-0077
  • Fax: 270-765-6243
Mailing address:
  • Phone: 808-433-3300
  • Fax: 808-433-1153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number50677
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: