Healthcare Provider Details

I. General information

NPI: 1366475568
Provider Name (Legal Business Name): HENRY CABOT LODGE BOHLER JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 01/07/2025
Certification Date: 01/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9412 CIVIC WAY APT 210
PROSPECT KY
40059-5103
US

IV. Provider business mailing address

9412 CIVIC WAY APT 210
PROSPECT KY
40059-5103
US

V. Phone/Fax

Practice location:
  • Phone: 502-373-0110
  • Fax:
Mailing address:
  • Phone: 502-444-5767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number38316
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number38316
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code207VB0002X
TaxonomyObesity Medicine (Obstetrics & Gynecology) Physician
License Number38316
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: