Healthcare Provider Details

I. General information

NPI: 1326070152
Provider Name (Legal Business Name): JEFFREY P SQUIRES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 01/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7950 W JEFFERSON BLVD
FORT WAYNE IN
46804-4140
US

IV. Provider business mailing address

3240B MALLARD COVE LN
FORT WAYNE IN
46804-2883
US

V. Phone/Fax

Practice location:
  • Phone: 260-435-7154
  • Fax: 260-435-7633
Mailing address:
  • Phone: 260-432-5867
  • Fax: 260-436-9013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number1028175
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: