Basic Information
| Provider Information | |||||||||
| NPI: | 1336126895 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOOIBROEK | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3702 NEW VISION DR | ||||||||
| Address2: | BLDG B | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603739728 | ||||||||
| FaxNumber: | 2604585664 | ||||||||
| Practice Location | |||||||||
| Address1: | 2710 LAKE AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468055412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603738070 | ||||||||
| FaxNumber: | 2603738071 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2005 | ||||||||
| LastUpdateDate: | 11/27/2019 | ||||||||
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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 | 208000000X | 01054479A | IN | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | 01054479A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00002092742 02 | 01 | UNITED | OTHER | 7559229 | 01 | AETNA | OTHER | 200330780 | 05 | IN | MEDICAID | 3937240024 | 01 | IN | MEDICARE DMEPOS | OTHER | 000000196870 | 01 | IN | ANTHEM | OTHER | 12184 | 01 | IN | PHYSICIANS HEALTH PLAN | OTHER |