Healthcare Provider Details

I. General information

NPI: 1508954322
Provider Name (Legal Business Name): CD EGNATZ MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1326 W US ROUTE 30
SCHERERVILLE IN
46375
US

IV. Provider business mailing address

1326 W US ROUTE 30
SCHERERVILLE IN
46375
US

V. Phone/Fax

Practice location:
  • Phone: 219-865-2691
  • Fax: 219-322-5928
Mailing address:
  • Phone: 219-865-2691
  • Fax: 219-322-5928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01019054A
License Number StateIN

VIII. Authorized Official

Name: DR. CHARLES DYKE EGNATZ
Title or Position: OWNER PRESIDENT
Credential: MD
Phone: 219-865-2691