Provider Demographics
NPI:1235940784
Name:FORT WAYNE DERMATOLOGY CONSULTANTS INC
Entity type:Organization
Organization Name:FORT WAYNE DERMATOLOGY CONSULTANTS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGGONER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-469-1444
Mailing Address - Street 1:7881 CARNEGIE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-5792
Mailing Address - Country:US
Mailing Address - Phone:260-436-8000
Mailing Address - Fax:260-434-0929
Practice Address - Street 1:7881 CARNEGIE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-5792
Practice Address - Country:US
Practice Address - Phone:260-436-8000
Practice Address - Fax:260-434-0929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-15
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN15D0974991OtherCLIA