Healthcare Provider Details

I. General information

NPI: 1669708020
Provider Name (Legal Business Name): SOFYA KUZNETSOV M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2009
Last Update Date: 10/23/2020
Certification Date: 10/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6420 DUTCHMANS PKWY STE 200
LOUISVILLE KY
40205-3373
US

IV. Provider business mailing address

PO BOX 776351
CHICAGO IL
60677-6351
US

V. Phone/Fax

Practice location:
  • Phone: 502-891-8300
  • Fax: 502-891-8388
Mailing address:
  • Phone: 502-272-5337
  • Fax: 502-272-5339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125.057550
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number51423
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number51423
License Number StateKY
# 4
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number51423
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: