Healthcare Provider Details

I. General information

NPI: 1124741780
Provider Name (Legal Business Name): CENTRAL KENTUCKY DERMATOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2022
Last Update Date: 07/10/2025
Certification Date: 07/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

249 E BRANNON RD
NICHOLASVILLE KY
40356-8059
US

IV. Provider business mailing address

249 E BRANNON RD
NICHOLASVILLE KY
40356-8059
US

V. Phone/Fax

Practice location:
  • Phone: 859-354-5455
  • Fax: 859-203-8833
Mailing address:
  • Phone: 859-354-5455
  • Fax: 859-203-8833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: TODD CLARK
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 859-608-9917