Basic Information
| Provider Information | |||||||||
| NPI: | 1124135967 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DRAKE | ||||||||
| FirstName: | FRED | ||||||||
| MiddleName: | DUANE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 221 S 6TH ST | ||||||||
| Address2: | |||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478074214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122423170 | ||||||||
| FaxNumber: | 8122353330 | ||||||||
| Practice Location | |||||||||
| Address1: | 1429 N 6TH ST | ||||||||
| Address2: | |||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478071037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122423170 | ||||||||
| FaxNumber: | 8122353330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 03/14/2013 | ||||||||
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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 | 207Y00000X | 01024937A | IN | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 0182870 | 01 | US DEPT OF LABOR | OTHER | 100250540 | 05 | IN | MEDICAID | 000000089620 | 01 | ANTHEM | OTHER | 040004682 | 01 | RAILROAD MCARE PALAMETTO | OTHER |