Healthcare Provider Details

I. General information

NPI: 1811959661
Provider Name (Legal Business Name): RUDOLPH JOSEPH TRIANA JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 09/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 MEDICAL CENTER CIR
MAYFIELD KY
42066-1194
US

IV. Provider business mailing address

1111 MEDICAL CENTER CIR
MAYFIELD KY
42066-1194
US

V. Phone/Fax

Practice location:
  • Phone: 270-251-4080
  • Fax:
Mailing address:
  • Phone: 270-251-4080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License NumberME92477
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number36944
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: