Healthcare Provider Details

I. General information

NPI: 1043448889
Provider Name (Legal Business Name): MR. LUIS J FABIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2009
Last Update Date: 07/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5207 SAINT GABRIEL CT
LOUISVILLE KY
40291-1622
US

IV. Provider business mailing address

5207 SAINT GABRIEL CT
LOUISVILLE KY
40291-1622
US

V. Phone/Fax

Practice location:
  • Phone: 502-550-0235
  • Fax:
Mailing address:
  • Phone: 502-550-0235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberF06-508-181
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: