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General NPI Number Information
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NPI Number | 1134373814
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Entity Type | Organization
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Legal Business Name | WESTPORT VILLAGE PEDIATRICS
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Dates
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Enumeration Date | 11/08/2008
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Last Update Date | 11/08/2008
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Provider Practice Location Address
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Address Line | 8134 NEW LAGRANGE RD STE 100
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City | LOUISVILLE
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State | KY
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Zip | 40222-4676
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Country | US
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Telephone | 502-412-0597
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Fax |
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Provider Business Mailing Address
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Address Line | 8134 NEW LAGRANGE RD STE 100
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City | LOUISVILLE
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State | KY
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Zip | 40222-4676
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Country | US
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Telephone | 502-412-0597
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. LESA SUTTON-DAVIS
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Credential | MD
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Telephone | 502-412-0597
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 36607
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License Number State | KY
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