Healthcare Provider Details

I. General information

NPI: 1780694794
Provider Name (Legal Business Name): JACQUELINE D COMBELLICK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 02/27/2025
Certification Date: 02/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11700 N MERIDIAN ST
CARMEL IN
46032-4656
US

IV. Provider business mailing address

250 N SHADELAND AVE SUITE 130
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-688-3139
  • Fax: 317-688-2664
Mailing address:
  • Phone: 317-963-0860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number01047186A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number01047186A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: