Healthcare Provider Details

I. General information

NPI: 1184032062
Provider Name (Legal Business Name): DEREK L. WEYHRAUCH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2014
Last Update Date: 07/12/2021
Certification Date: 06/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

731 E. BROADWAY
LOUISVILLE KY
40202
US

IV. Provider business mailing address

743 E. BROADWAY #300
LOUISVILLE KY
40202
US

V. Phone/Fax

Practice location:
  • Phone: 502-584-3200
  • Fax: 502-584-3333
Mailing address:
  • Phone: 502-584-3200
  • Fax: 502-584-3333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number59618
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number10358523-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: