Healthcare Provider Details

I. General information

NPI: 1124004080
Provider Name (Legal Business Name): ABRAHAM KURUVILLA MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2005
Last Update Date: 02/03/2023
Certification Date: 02/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 S ENGLISH STATION RD
LOUISVILLE KY
40245-3996
US

IV. Provider business mailing address

801 YORK ST
MANITOWOC WI
54220-4630
US

V. Phone/Fax

Practice location:
  • Phone: 502-753-0056
  • Fax: 502-753-0626
Mailing address:
  • Phone: 920-663-9008
  • Fax: 920-684-1439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number55515
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: