Healthcare Provider Details

I. General information

NPI: 1790216778
Provider Name (Legal Business Name): JUSTIN TRAVIS GAGEL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2017
Last Update Date: 05/10/2021
Certification Date: 05/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 S LIMESTONE CTW 304
LEXINGTON KY
40536
US

IV. Provider business mailing address

1932 ALCOA HWY STE 255
KNOXVILLE TN
37920-1508
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-9918
  • Fax: 859-323-1197
Mailing address:
  • Phone: 865-244-2030
  • Fax: 865-684-1196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number62873
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberR4397
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: