Healthcare Provider Details

I. General information

NPI: 1447994868
Provider Name (Legal Business Name): EPHRAIM OTIENO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2022
Last Update Date: 12/14/2025
Certification Date: 04/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 S JACKSON ST FL STREET3
LOUISVILLE KY
40202-1622
US

IV. Provider business mailing address

609 E MAIN ST APT 253
LOUISVILLE KY
40202-1451
US

V. Phone/Fax

Practice location:
  • Phone: 502-852-5666
  • Fax:
Mailing address:
  • Phone: 859-625-2485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0000000
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: