Provider Demographics
NPI:1679527923
Name:GLASS, KATHRYN J (MD)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:J
Last Name:GLASS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:LEONA
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:305 GOLF CLUB LN
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42066-1316
Mailing Address - Country:US
Mailing Address - Phone:270-970-1217
Mailing Address - Fax:
Practice Address - Street 1:305 GOLF CLUB LN
Practice Address - Street 2:
Practice Address - City:MAYFIELD
Practice Address - State:KY
Practice Address - Zip Code:42066-1316
Practice Address - Country:US
Practice Address - Phone:270-970-1217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38858207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64085392Medicaid
KYI13220Medicare UPIN
KY64085392Medicaid