Basic Information
Provider Information | |||||||||
NPI: | 1184689101 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DANNENBERG | ||||||||
FirstName: | RICHARD | ||||||||
MiddleName: | JOSEPH | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | UNIVERSITY OF KENTUCKY | ||||||||
Address2: | 740 S. LIMESTONE | ||||||||
City: | LEXINGTON | ||||||||
State: | KY | ||||||||
PostalCode: | 405360284 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8593235867 | ||||||||
FaxNumber: | 8593234781 | ||||||||
Practice Location | |||||||||
Address1: | UNIVERSITY OF KENTUCKY | ||||||||
Address2: | 740 S. LIMESTONE | ||||||||
City: | LEXINGTON | ||||||||
State: | KY | ||||||||
PostalCode: | 405360284 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8593235867 | ||||||||
FaxNumber: | 8593234781 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/20/2006 | ||||||||
LastUpdateDate: | 04/05/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 27830 | MN | N |   | Allopathic & Osteopathic Physicians | Ophthalmology |   | 207W00000X | 20875 | KY | Y |   | Allopathic & Osteopathic Physicians | Ophthalmology |   |
ID Information
ID | Type | State | Issuer | Description | 110565 | 01 | MN | EYEMED | OTHER | 114683 | 01 | MN | U-CARE | OTHER | PREFERRED ONE | 01 | MN | 826041022794 | OTHER | BCBSM | 01 | MN | 43034DA | OTHER | HEALTH PARTNERS | 01 | MN | 19379 | OTHER | MEDICA | 01 | MN | 0808759 | OTHER | 475067500 | 05 | MN |   | MEDICAID |