Individual
DR. JACK DALE TOLLIVER JR.
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
2120 CAVE SPRING PL, LOUISVILLE, KY 40223-1562
(502) 931-1373
Mailing address
2120 CAVE SPRING PL, LOUISVILLE, KY 40223-1562
(502) 931-1373
Taxonomy
Speciality
Code
Description
License number
State
173000000X
Legal Medicine
Primary
21479
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
21479
KENTUCKY BOARD OF MEDICAL LICENSURE
KY
Enumeration date
03/01/2016
Last updated
03/01/2016
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