Healthcare Provider Details

I. General information

NPI: 1952399669
Provider Name (Legal Business Name): JUAN GUSTAVO POLO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2005
Last Update Date: 02/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 E GRAY ST STE. 670
LOUISVILLE KY
40202-1900
US

IV. Provider business mailing address

234 E GRAY ST STE. 670
LOUISVILLE KY
40202-1900
US

V. Phone/Fax

Practice location:
  • Phone: 502-629-4525
  • Fax: 502-629-4529
Mailing address:
  • Phone: 502-629-4525
  • Fax: 502-629-4529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number36067
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: