Healthcare Provider Details

I. General information

NPI: 1861621880
Provider Name (Legal Business Name): JENNIFER PHAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2009
Last Update Date: 11/27/2023
Certification Date: 10/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3113 N BROADWAY STREET
ANDERSON IN
46012-1261
US

IV. Provider business mailing address

6626 E 75TH ST SUITE 500
INDIANAPOLIS IN
46250-2805
US

V. Phone/Fax

Practice location:
  • Phone: 765-298-4660
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number11014885A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: