Basic Information
Provider Information | |||||||||
NPI: | 1801870639 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOHNKE | ||||||||
FirstName: | KATHLEEN | ||||||||
MiddleName: | D. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 11109 PARKVIEW PLAZA DR # 117 | ||||||||
Address2: |   | ||||||||
City: | FORT WAYNE | ||||||||
State: | IN | ||||||||
PostalCode: | 468451701 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 11123 PARKVIEW PLAZA DR | ||||||||
Address2: | SUITE 106 | ||||||||
City: | FORT WAYNE | ||||||||
State: | IN | ||||||||
PostalCode: | 468451707 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2606726550 | ||||||||
FaxNumber: | 2606726559 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/05/2005 | ||||||||
LastUpdateDate: | 11/09/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/09/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 01049000A | IN | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208000000X | 01049000A | IN | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 7762243 | 01 |   | AETNA | OTHER | 12182 | 01 | IN | PHYSICIANS HEALTH PLAN | OTHER | 000000200308 | 01 | IN | ANTHEM | OTHER | 200342340 | 05 | IN |   | MEDICAID | 3937240021 | 01 | IN | MEDICARE DMEPOS | OTHER | 3937240024 | 01 | IN | MEDICARE DMEPOS | OTHER | 00002092719 02 | 01 |   | UNITED HEALTHCARE | OTHER |