Provider Demographics
NPI:1538253612
Name:IGLEHART, BRYAN THOMAS JR (MD)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:THOMAS
Last Name:IGLEHART
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 950248
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0248
Mailing Address - Country:US
Mailing Address - Phone:502-489-5730
Mailing Address - Fax:502-489-5753
Practice Address - Street 1:3828 BARDSTOWN RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-1527
Practice Address - Country:US
Practice Address - Phone:502-459-4900
Practice Address - Fax:502-454-0591
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY22223207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64222235Medicaid
D32686Medicare UPIN
KY64222235Medicaid