Healthcare Provider Details

I. General information

NPI: 1033282546
Provider Name (Legal Business Name): VEDRAN USCHUPLICH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 09/27/2023
Certification Date: 09/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 LAKE AVE
FORT WAYNE IN
46805-5100
US

IV. Provider business mailing address

2121 LAKE AVE
FORT WAYNE IN
46805-5100
US

V. Phone/Fax

Practice location:
  • Phone: 260-426-5431
  • Fax:
Mailing address:
  • Phone: 260-426-5431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License NumberMD435003
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License NumberME141861
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberME141861
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberMD435003
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: