Healthcare Provider Details

I. General information

NPI: 1053605394
Provider Name (Legal Business Name): MR. TODD DOUGLAS DEETSCH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2011
Last Update Date: 06/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 LINNEY AVE
LOUISVILLE KY
40243-1014
US

IV. Provider business mailing address

208 LINNEY AVE
LOUISVILLE KY
40243-1014
US

V. Phone/Fax

Practice location:
  • Phone: 502-693-1037
  • Fax: 502-245-2490
Mailing address:
  • Phone: 502-693-1037
  • Fax: 502-245-2490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: