Basic Information
| Provider Information | |||||||||
| NPI: | 1437243268 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | KATHLEEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 936 | ||||||||
| Address2: | |||||||||
| City: | LONDON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407430936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063307818 | ||||||||
| FaxNumber: | 6063307825 | ||||||||
| Practice Location | |||||||||
| Address1: | 160 N EAGLE CREEK DR | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405092121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592630022 | ||||||||
| FaxNumber: | 8592634666 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 08/07/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 24819 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 000000195176 | 01 | KY | ANTHEM | OTHER | 64248198 | 05 | KY | MEDICAID |