Healthcare Provider Details

I. General information

NPI: 1861492993
Provider Name (Legal Business Name): DOUGLAS C DEDELOW DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 07/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 S LAKE PARK AVE STE 205
HOBART IN
46342-6790
US

IV. Provider business mailing address

9660 WICKER AVENUE
ST JOHN IN
46373-9487
US

V. Phone/Fax

Practice location:
  • Phone: 219-942-8620
  • Fax: 219-942-6356
Mailing address:
  • Phone: 219-226-2203
  • Fax: 219-226-2202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number02001822A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: