Healthcare Provider Details

I. General information

NPI: 1336193465
Provider Name (Legal Business Name): ANGELINO S YSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: ANGELINO YSON MD

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 12/01/2020
Certification Date: 12/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4003 KRESGE WAY SUITE 400
LOUISVILLE KY
40207-4652
US

IV. Provider business mailing address

PO BOX 950248
LOUISVILLE KY
40295-0248
US

V. Phone/Fax

Practice location:
  • Phone: 502-895-4263
  • Fax: 502-899-5488
Mailing address:
  • Phone: 502-253-1035
  • Fax: 502-253-1037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number27613
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: