1700889102 NPI number — STEPHEN M OFFUTT DPM

Table of content: STEPHEN M OFFUTT DPM (NPI 1700889102)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700889102 NPI number — STEPHEN M OFFUTT DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OFFUTT
Provider First Name:
STEPHEN
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
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:
1700889102
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8780 PURDUE RD
Provider Second Line Business Mailing Address:
SUITE # 7
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46268-6129
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-471-8701
Provider Business Mailing Address Fax Number:
317-471-8702

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8780 PURDUE RD
Provider Second Line Business Practice Location Address:
SUITE # 7
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46268-6129
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-471-8701
Provider Business Practice Location Address Fax Number:
317-471-8702
Provider Enumeration Date:
05/31/2005

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: 213ES0103X , with the licence number:  0700991A , 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: P01287668 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 07000991A . This is a "STATE LICENSE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200958540 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 11267445 . This is a "CAQH" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200268880E , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com