Provider Demographics
NPI:1780783456
Name:MUDD, LOUIS GERALD (MD)
Entity type:Individual
Prefix:
First Name:LOUIS
Middle Name:GERALD
Last Name:MUDD
Suffix:
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 1:720 E 2ND AVE
Mailing Address - Street 2:STE 300
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101
Mailing Address - Country:US
Mailing Address - Phone:270-843-5037
Mailing Address - Fax:270-796-2140
Practice Address - Street 1:720 E 2ND AVE
Practice Address - Street 2:STE 300
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101
Practice Address - Country:US
Practice Address - Phone:270-843-5037
Practice Address - Fax:270-796-2140
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY299542084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64299548Medicaid
F17849Medicare UPIN
1594701Medicare ID - Type Unspecified