Healthcare Provider Details

I. General information

NPI: 1043263346
Provider Name (Legal Business Name): PRAVEEN SESHABHATTAR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 11/09/2023
Certification Date: 11/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 BLUEGRASS AVE HIPS DEPT
LOUISVILLE KY
40215-1161
US

IV. Provider business mailing address

PO BOX 909
LOUISVILLE KY
40201-0909
US

V. Phone/Fax

Practice location:
  • Phone: 502-367-3360
  • Fax: 502-367-3365
Mailing address:
  • Phone: 502-367-3360
  • Fax: 502-367-3365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35087541
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number42999
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number42999
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: