Healthcare Provider Details

I. General information

NPI: 1811950256
Provider Name (Legal Business Name): DAVID WAYNE SUETHOLZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 03/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2378 GRANDVIEW DR
FORT MITCHELL KY
41017-1633
US

IV. Provider business mailing address

2378 GRANDVIEW DR
FORT MITCHELL KY
41017-1633
US

V. Phone/Fax

Practice location:
  • Phone: 859-341-1122
  • Fax: 859-341-1171
Mailing address:
  • Phone: 859-341-1122
  • Fax: 859-341-1171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number18013
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: