1376593046 NPI number — DR. WAYNE JAMES VON BARGEN PH.D.

Table of content: DR. WAYNE JAMES VON BARGEN PH.D. (NPI 1376593046)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376593046 NPI number — DR. WAYNE JAMES VON BARGEN PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VON BARGEN
Provider First Name:
WAYNE
Provider Middle Name:
JAMES
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.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:
1376593046
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1910 SAINT JOE CENTER RD
Provider Second Line Business Mailing Address:
SUITE 44
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46825-5000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-471-8033
Provider Business Mailing Address Fax Number:
260-471-8107

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1910 SAINT JOE CENTER RD
Provider Second Line Business Practice Location Address:
SUITE 44
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46825-5000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-471-8033
Provider Business Practice Location Address Fax Number:
260-471-8107
Provider Enumeration Date:
05/11/2006

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: 103TC0700X , with the licence number:  20010203A , 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)





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