Healthcare Provider Details

I. General information

NPI: 1639584873
Provider Name (Legal Business Name): RYAN SETH ROTTMAN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2014
Last Update Date: 11/14/2021
Certification Date: 11/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7900 SHELBYVILLE RD STE A15
LOUISVILLE KY
40222
US

IV. Provider business mailing address

7900 SHELBYVILLE RD STE A15
LOUISVILLE KY
40222-5463
US

V. Phone/Fax

Practice location:
  • Phone: 502-327-8568
  • Fax:
Mailing address:
  • Phone: 502-327-8568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number2133DT
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2133DT
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: