Basic Information
| Provider Information | |||||||||
| NPI: | 1336193465 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YSON | ||||||||
| FirstName: | ANGELINO | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | YSON | ||||||||
| OtherFirstName: | ANGELINO | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 950248 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402950248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022531035 | ||||||||
| FaxNumber: | 5022531037 | ||||||||
| Practice Location | |||||||||
| Address1: | 4003 KRESGE WAY | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028954263 | ||||||||
| FaxNumber: | 5028995488 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 12/01/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | 27613 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 000000575262 | 01 | KY | ANTHEM - NCMA | OTHER | P00655716 | 01 | KY | RAILROAD MCR - NMA | OTHER | 3534949000 | 01 | KY | PASSPORT ADVTG - NMA | OTHER | 3759061000 | 01 | KY | PASSPORT ADVTG - NCMA | OTHER | 64276132 | 05 | KY | MEDICAID | 097760 | 01 | KY | SIHO | OTHER | 2432738000 | 05 | KY | MEDICAID | 200035830 | 01 | IN | MEDICAID-IN - NMA | OTHER | 50027043 | 01 | KY | PASSPORT - NCMA | OTHER | 5020165 | 01 | KY | PASSPORT - NMA | OTHER | 000023033Q | 01 | KY | HUMANA | OTHER | 00533053 | 01 | KY | MEDICARE - KY - NMA | OTHER | 0994672 | 01 | KY | CIGNA - NMA | OTHER | 000000614192 | 01 | KY | ANTHEM - NMA | OTHER | 64276132 | 01 | KY | MEDICAID-KY - NMA | OTHER |