Healthcare Provider Details

I. General information

NPI: 1194219063
Provider Name (Legal Business Name): JULIE M. RALLO O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2018
Last Update Date: 03/03/2021
Certification Date: 03/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 POPLAR LEVEL RD
LOUISVILLE KY
40213
US

IV. Provider business mailing address

4000 POPLAR LEVEL RD
LOUISVILLE KY
40213-1524
US

V. Phone/Fax

Practice location:
  • Phone: 502-459-2020
  • Fax: 502-456-9121
Mailing address:
  • Phone: 502-459-2020
  • Fax: 502-456-9121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2111DT
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: