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General NPI Number Information
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NPI Number | 1326070152
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Entity Type | Individual
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Provider Name | JEFFREY P SQUIRES MD
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Gender | Male
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Dates
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Enumeration Date | 07/06/2006
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Last Update Date | 01/28/2011
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Provider Practice Location Address
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Address Line | 7950 W JEFFERSON BLVD
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City | FORT WAYNE
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State | IN
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Zip | 46804-4140
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Country | US
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Telephone | 260-435-7154
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Fax | 260-435-7633
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Provider Business Mailing Address
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Address Line | 3240B MALLARD COVE LN
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City | FORT WAYNE
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State | IN
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Zip | 46804-2883
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Country | US
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Telephone | 260-432-5867
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Fax | 260-436-9013
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207ZP0102X
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Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
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License Number | 1028175
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License Number State | IN
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