Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | 00209 | KY |
Y | 222Z00000X | Podiatrist | 00209 | KY |
NPI | 1013094978 |
---|---|
Provider Name | Dr. Thomas Wayne Childress JR. |
First Address | Louisville, KY 40217-1319 |
Second Address | Louisville, KY 40217-1319 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/10/2006 |
Last Update Date | 13/05/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U46016 | (02) |