Basic Information
| Provider Information | |||||||||
| NPI: | 1285892752 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MASTBAUM ENDOCRINOLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7900 W JEFFERSON BLVD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468044128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2609697100 | ||||||||
| FaxNumber: | 2609697771 | ||||||||
| Practice Location | |||||||||
| Address1: | 7950 W JEFFERSON BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468044140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604357001 | ||||||||
| FaxNumber: | 2609697101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2008 | ||||||||
| LastUpdateDate: | 05/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | HATTERY | ||||||||
| AuthorizedOfficialFirstName: | JODIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 2609697173 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | 01041346 | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
No ID Information.