Healthcare Provider Details

I. General information

NPI: 1881693083
Provider Name (Legal Business Name): LONNIE R AILES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 02/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1551 STURDY RD
VALPARAISO IN
46383-7883
US

IV. Provider business mailing address

1551 STURDY RD
VALPARAISO IN
46383-7883
US

V. Phone/Fax

Practice location:
  • Phone: 219-464-1365
  • Fax: 219-464-7815
Mailing address:
  • Phone: 219-464-1365
  • Fax: 219-464-7815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01026986A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: