Healthcare Provider Details

I. General information

NPI: 1851421952
Provider Name (Legal Business Name): RENEE M HEUSTIS MD ED
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6002 BROWNSBORO PARK BLVD
LOUISVILLE KY
40207
US

IV. Provider business mailing address

6002 BROWNSBORO PARK BLVD
LOUISVILLE KY
40207
US

V. Phone/Fax

Practice location:
  • Phone: 502-897-3232
  • Fax: 502-895-4389
Mailing address:
  • Phone: 502-897-3232
  • Fax: 502-895-4389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number39220
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: