Basic Information
| Provider Information | |||||||||
| NPI: | 1568464972 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DUSMAN | ||||||||
| FirstName: | RAYMOND | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1234 E. DUPONT RD. | ||||||||
| Address2: | 3 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468251545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603739700 | ||||||||
| FaxNumber: | 2603739740 | ||||||||
| Practice Location | |||||||||
| Address1: | 1819 CAREW ST | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468054705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604814700 | ||||||||
| FaxNumber: | 2604814808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2005 | ||||||||
| LastUpdateDate: | 03/20/2013 | ||||||||
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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 | 207RC0000X | 01033566A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0001X | 01033566A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology |
ID Information
| ID | Type | State | Issuer | Description | P00785633 | 01 | IN | R.R. MEDICARE | OTHER | 100321280 | 05 | IN | MEDICAID | 060070557 | 01 | IN | RR MEDICARE | OTHER | 0783933 | 05 | OH | MEDICAID | 000000641075 | 01 | IN | ANTHEM | OTHER |