Basic Information
| Provider Information | |||||||||
| NPI: | 1083053094 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORELL DIAZ | ||||||||
| FirstName: | FERNANDO | ||||||||
| MiddleName: | JAVIER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MORELL | ||||||||
| OtherFirstName: | FERNANDO | ||||||||
| OtherMiddleName: | JAVIER | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2101 JACKSON ST STE 115 | ||||||||
| Address2: | |||||||||
| City: | ANDERSON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460164386 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2101 JACKSON ST STE 115 | ||||||||
| Address2: | |||||||||
| City: | ANDERSON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460164386 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7656436961 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2013 | ||||||||
| LastUpdateDate: | 06/01/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 35.133844 | OH | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | 01087067A | IN | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 0301637 | 05 | OH | MEDICAID |