Healthcare Provider Details

I. General information

NPI: 1013190602
Provider Name (Legal Business Name): JERRY W CONNERS MD PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2007
Last Update Date: 12/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 NORTH GRAND AVENUE SUITE 200
FT THOMAS KY
41075
US

IV. Provider business mailing address

40 NORTH GRAND AVENUE SUITE 200
FT THOMAS KY
41075
US

V. Phone/Fax

Practice location:
  • Phone: 859-781-2700
  • Fax: 859-781-2712
Mailing address:
  • Phone: 859-781-2700
  • Fax: 859-781-2712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number15481
License Number StateKY

VIII. Authorized Official

Name: JERRY W CONNERS
Title or Position: MD
Credential: MD
Phone: 859-781-2700