Healthcare Provider Details

I. General information

NPI: 1104400522
Provider Name (Legal Business Name): JAKE FRIES DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2021
Last Update Date: 08/28/2025
Certification Date: 08/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8450 NORTHWEST BLVD
INDIANAPOLIS IN
46278-1381
US

IV. Provider business mailing address

8450 NORTHWEST BLVD
INDIANAPOLIS IN
46278-1381
US

V. Phone/Fax

Practice location:
  • Phone: 317-802-2000
  • Fax:
Mailing address:
  • Phone: 317-802-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number02007367A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number346505
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: