Healthcare Provider Details

I. General information

NPI: 1881030088
Provider Name (Legal Business Name): FACIAL PLASTIC SURGERY & DERMATOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2013
Last Update Date: 08/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

448 LEWIS HARGETT CIR STE 240
LEXINGTON KY
40503-3594
US

IV. Provider business mailing address

3070 LAKECREST CIR STE. 400-264
LEXINGTON KY
40513-1937
US

V. Phone/Fax

Practice location:
  • Phone: 859-226-0206
  • Fax: 859-226-0207
Mailing address:
  • Phone: 859-226-0206
  • Fax: 859-226-0207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number34192
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number34192
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number34192
License Number StateKY

VIII. Authorized Official

Name: SAMUEL JACK PRUDEN II
Title or Position: OWNER
Credential: MD
Phone: 859-226-0206