Basic Information
| Provider Information | |||||||||
| NPI: | 1396165866 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SEBASTIAN | ||||||||
| FirstName: | SONY | ||||||||
| MiddleName: | THEKKETHALA | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2379 | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411052379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064086200 | ||||||||
| FaxNumber: | 6064086612 | ||||||||
| Practice Location | |||||||||
| Address1: | 2201 LEXINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411012843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064084000 | ||||||||
| FaxNumber: | 6064086825 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2014 | ||||||||
| LastUpdateDate: | 12/14/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 04143 | KY | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 04143 | KY | N | Allopathic & Osteopathic Physicians | Family Medicine | 208M00000X | 04143 | KY | Y | Allopathic & Osteopathic Physicians | Hospitalist |
No ID Information.