Healthcare Provider Details

I. General information

NPI: 1083145874
Provider Name (Legal Business Name): TRAVIS MASSENGALE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2017
Last Update Date: 05/09/2020
Certification Date: 05/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 HOSPITAL WAY
SOMERSET KY
42503-2872
US

IV. Provider business mailing address

350 HOSPITAL WAY
SOMERSET KY
42503-2872
US

V. Phone/Fax

Practice location:
  • Phone: 606-451-2624
  • Fax: 606-451-5506
Mailing address:
  • Phone: 606-451-2624
  • 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 StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number04599
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: