Healthcare Provider Details

I. General information

NPI: 1376521351
Provider Name (Legal Business Name): MARTHA J DWENGER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 10/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 TECHNOLOGY CENTER DR
INDIANAPOLIS IN
46278-6013
US

IV. Provider business mailing address

5901 TECHNOLOGY CENTER DR
INDIANAPOLIS IN
46278-6013
US

V. Phone/Fax

Practice location:
  • Phone: 317-328-4777
  • Fax: 317-715-9965
Mailing address:
  • Phone: 317-328-5050
  • Fax: 317-328-5053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number01037042A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: