Basic Information
| Provider Information | |||||||||
| NPI: | 1033265731 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEER PARK FAMILY DOCTORS PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1603 STEVENS AVE | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402051042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024515955 | ||||||||
| FaxNumber: | 5024515925 | ||||||||
| Practice Location | |||||||||
| Address1: | 1603 STEVENS AVE | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402051042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024515955 | ||||||||
| FaxNumber: | 5024515925 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ROSZELL | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PHYSICIAN PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 5024515955 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 37462 | KY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 65939753 | 05 | KY | MEDICAID |