1790788255 NPI number — DR. DALLIS MARK BOWDITCH M.D.

Table of content: VICTOR M PINEY IBARRA (NPI 1780032698)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790788255 NPI number — DR. DALLIS MARK BOWDITCH M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOWDITCH
Provider First Name:
DALLIS
Provider Middle Name:
MARK
Provider Name Prefix Text:
DR.
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:
1790788255
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/01/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1201 MICHIGAN AVE
Provider Second Line Business Mailing Address:
SUITE 140
Provider Business Mailing Address City Name:
LOGANSPORT
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46947-1580
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-753-1462
Provider Business Mailing Address Fax Number:
574-753-1465

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1201 MICHIGAN AVE
Provider Second Line Business Practice Location Address:
SUITE 140
Provider Business Practice Location Address City Name:
LOGANSPORT
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46947-1580
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-753-1462
Provider Business Practice Location Address Fax Number:
574-753-1465
Provider Enumeration Date:
05/27/2005

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: 207Q00000X , with the licence number:  01032465A , 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: 4216390 . This is a "AETNA ID" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 100070810 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000546802 . This is a "ANTHEM BLUE CROSS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6148784003 . This is a "CIGNA ID" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 080096741 . This is a "MEDICARE RAILROAD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 112810C . This is a "OLD MEDICARE ID #" identifier . This identifiers is of the category "OTHER".




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