Healthcare Provider Details

I. General information

NPI: 1891879219
Provider Name (Legal Business Name): JOHN P OLIPHANT MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 02/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3427 STONY SPRING CIR
LOUISVILLE KY
40220-5437
US

IV. Provider business mailing address

3427 STONY SPRING CIR
LOUISVILLE KY
40220-5437
US

V. Phone/Fax

Practice location:
  • Phone: 502-493-9994
  • Fax: 502-493-9991
Mailing address:
  • Phone: 502-493-9994
  • Fax: 502-493-9991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number30518
License Number StateKY

VIII. Authorized Official

Name: JOHN P OLIPHANT
Title or Position: SOLE MEMBER OWNER
Credential: MD
Phone: 502-493-9994