1194707117 NPI number — ENRIQUE EDUARDO INFANTE M.D.

Table of content: ENRIQUE EDUARDO INFANTE M.D. (NPI 1194707117)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194707117 NPI number — ENRIQUE EDUARDO INFANTE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
INFANTE
Provider First Name:
ENRIQUE
Provider Middle Name:
EDUARDO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194707117
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/19/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1887
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELKHART
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46515-1887
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-389-0542
Provider Business Mailing Address Fax Number:
574-522-8505

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1215 LAWN AVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
ELKHART
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46514-2450
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-293-2893
Provider Business Practice Location Address Fax Number:
574-293-1298
Provider Enumeration Date:
11/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  4301084601 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 01065587A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200908830 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000573936 . This is a "BCBS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000702255 . This is a "ANTHEM - WCCC" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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