Basic Information
| Provider Information | |||||||||
| NPI: | 1679688295 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MORAN | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 CAREW ST | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468054765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603739728 | ||||||||
| FaxNumber: | 2603739740 | ||||||||
| Practice Location | |||||||||
| Address1: | 5104 N CLINTON ST | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468255720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604222481 | ||||||||
| FaxNumber: | 2609693067 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| LastUpdateDate: | 10/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01044168A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00698427 | 01 | IN | MEDICARE RR | OTHER | 200150750 | 05 | IN | MEDICAID | 000000595587 | 01 | IN | ANTHEM | OTHER |