Basic Information
| Provider Information | |||||||||
| NPI: | 1639132418 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOUGENDOBLER | ||||||||
| FirstName: | DUANE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1234 E. DUPONT RD. | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468251545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603739700 | ||||||||
| FaxNumber: | 2604585446 | ||||||||
| Practice Location | |||||||||
| Address1: | 2003 STULTS ROAD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | HUNTINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467501291 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603553250 | ||||||||
| FaxNumber: | 2603553259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2006 | ||||||||
| LastUpdateDate: | 09/29/2009 | ||||||||
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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 | 01031511A | IN | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 100365590 | 05 | IN | MEDICAID | 100365590A | 05 | IN | MEDICAID | 000000543343 | 01 | IN | ANTHEM | OTHER | 000000083942 | 01 | IN | BLUE CROSS BLUE SHIELD | OTHER |