Healthcare Provider Details

I. General information

NPI: 1245298306
Provider Name (Legal Business Name): GREGORY FUQUA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 11/27/2024
Certification Date: 11/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 LIMESTONE ST S STE 1B
FRANKFORT KY
40601-4320
US

IV. Provider business mailing address

PO BOX 776351
CHICAGO IL
60677-6351
US

V. Phone/Fax

Practice location:
  • Phone: 502-665-8375
  • Fax: 502-665-8376
Mailing address:
  • Phone: 502-665-8375
  • Fax: 502-665-8376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number29659
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: