Healthcare Provider Details

I. General information

NPI: 1104825934
Provider Name (Legal Business Name): IVAN DAVID MORRIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 12/04/2020
Certification Date: 12/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 BEVINS LN STE C
GEORGETOWN KY
40324-6120
US

IV. Provider business mailing address

210 BEVINS LN STE C
GEORGETOWN KY
40324-6120
US

V. Phone/Fax

Practice location:
  • Phone: 502-868-0622
  • Fax: 502-868-9097
Mailing address:
  • Phone: 502-868-0622
  • Fax: 502-868-9097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number39654
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: