Basic Information
| Provider Information | |||||||||
| NPI: | 1437114048 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | UPTON | ||||||||
| FirstName: | ROY | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 950248 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402950248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022382801 | ||||||||
| FaxNumber: | 5022382835 | ||||||||
| Practice Location | |||||||||
| Address1: | 4003 KRESGE WAY | ||||||||
| Address2: | STE 228 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028935100 | ||||||||
| FaxNumber: | 5028938408 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2006 | ||||||||
| LastUpdateDate: | 10/25/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 20067 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64200678 | 05 | KY | MEDICAID |