1831151869 NPI number — SHAWN E KIDDER DO

Table of content: SHAWN E KIDDER DO (NPI 1831151869)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831151869 NPI number — SHAWN E KIDDER DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIDDER
Provider First Name:
SHAWN
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1831151869
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:
1234 E DUPONT RD
Provider Second Line Business Mailing Address:
SUITE 3
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46825-1545
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-373-9700
Provider Business Mailing Address Fax Number:
260-373-9740

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2235 DUBOIS DRIVE
Provider Second Line Business Practice Location Address:
NULL
Provider Business Practice Location Address City Name:
WARSAW
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46580-3212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-371-2625
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/05/2006

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: 207Q00000X , with the licence number:  IN02001281 , 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: 200089430 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000634019 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000664741 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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