Healthcare Provider Details

I. General information

NPI: 1104763390
Provider Name (Legal Business Name): FORD DERMATOLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3101 PARISA DR
PADUCAH KY
42003-4584
US

IV. Provider business mailing address

3101 PARISA DR
PADUCAH KY
42003-4584
US

V. Phone/Fax

Practice location:
  • Phone: 270-408-1850
  • Fax:
Mailing address:
  • Phone: 270-408-1850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. HALDEN HEATH FORD
Title or Position: OWNER
Credential: MD
Phone: 270-408-1850