Healthcare Provider Details

I. General information

NPI: 1396728358
Provider Name (Legal Business Name): JOHN P TUTTLE JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 N EAGLE CREEK STE 301
LEXINGTON KY
40509
US

IV. Provider business mailing address

160 N EAGLE CREEK STE 301
LEXINGTON KY
40509
US

V. Phone/Fax

Practice location:
  • Phone: 859-263-1300
  • Fax: 859-263-4395
Mailing address:
  • Phone: 859-263-1300
  • Fax: 859-263-4395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number19237
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: