Healthcare Provider Details

I. General information

NPI: 1104299593
Provider Name (Legal Business Name): DAVID MALDONADO D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2015
Last Update Date: 06/12/2023
Certification Date: 06/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 E COOLSPRING AVE STE 2D
MICHIGAN CITY IN
46360-6312
US

IV. Provider business mailing address

PO BOX 781076
DETROIT MI
48278-1076
US

V. Phone/Fax

Practice location:
  • Phone: 219-878-5037
  • Fax: 219-873-2903
Mailing address:
  • Phone: 317-528-4800
  • Fax: 317-865-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5101022140
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02005611A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: