Basic Information
| Provider Information | |||||||||
| NPI: | 1336141324 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LELONEK | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | MD | ||||||||
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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: | 7956 W JEFFERSON BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468044140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604352836 | ||||||||
| FaxNumber: | 2604356726 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2005 | ||||||||
| LastUpdateDate: | 05/02/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 01037618A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000095605 | 01 | IN | BCBS | OTHER | 100360500 | 05 | IN | MEDICAID |