Basic Information
| Provider Information | |||||||||
| NPI: | 1063496925 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRONIN | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | II | ||||||||
| Credential: | MD, PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6920 POINTE INVERNESS WAY STE 200 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468047934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604793514 | ||||||||
| FaxNumber: | 2604793520 | ||||||||
| Practice Location | |||||||||
| Address1: | 7910 W JEFFERSON BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468044159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604356275 | ||||||||
| FaxNumber: | 2604356279 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2005 | ||||||||
| LastUpdateDate: | 09/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204F00000X | 01082638A | IN | Y | Allopathic & Osteopathic Physicians | Transplant Surgery |
ID Information
| ID | Type | State | Issuer | Description | 001419002 | 05 | CT | MEDICAID | 67155103 | 05 | CO | MEDICAID | 1063496925 | 05 | WI | MEDICAID |