Healthcare Provider Details

I. General information

NPI: 1710984273
Provider Name (Legal Business Name): KENNETH LEE ODER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 07/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12615 TAYLORSVILLE RD
LOUISVILLE KY
40299-4452
US

IV. Provider business mailing address

PO BOX 776351
CHICAGO IL
60677-6351
US

V. Phone/Fax

Practice location:
  • Phone: 502-261-1595
  • Fax: 502-261-1590
Mailing address:
  • Phone: 502-588-9490
  • Fax: 502-272-5116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25195
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: