Provider Demographics
NPI:1871559302
Name:BESSETTE, JEFFREY R (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:R
Last Name:BESSETTE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3707 NEW VISION DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1702
Mailing Address - Country:US
Mailing Address - Phone:260-471-9466
Mailing Address - Fax:260-484-5919
Practice Address - Street 1:3707 NEW VISION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845
Practice Address - Country:US
Practice Address - Phone:260-471-9466
Practice Address - Fax:260-484-5919
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010344302085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100323820Medicaid
IN147380HMedicare ID - Type Unspecified
IN925240BMedicare ID - Type Unspecified
IN162860BMedicare ID - Type Unspecified
IN194930VMedicare ID - Type Unspecified
INE41536Medicare UPIN
IN055740MMedicare ID - Type Unspecified
IN924750MMedicare ID - Type Unspecified
IN163520BMedicare ID - Type Unspecified
IN191150CMedicare ID - Type Unspecified
OHBE41111371Medicare ID - Type Unspecified