Basic Information
| Provider Information | |||||||||
| NPI: | 1952389777 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ESTUS | ||||||||
| FirstName: | JANICE | ||||||||
| MiddleName: | LOUISE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MALLINAK | ||||||||
| OtherFirstName: | JANICE | ||||||||
| OtherMiddleName: | LOUISE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1055 DAVE RUN RD | ||||||||
| Address2: | STE 200 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592694668 | ||||||||
| FaxNumber: | 8592665577 | ||||||||
| Practice Location | |||||||||
| Address1: | 1055 DAVE RUN RD | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592694668 | ||||||||
| FaxNumber: | 8592665577 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2006 | ||||||||
| LastUpdateDate: | 01/05/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 30920 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64002447 | 05 | KY | MEDICAID |