MEDICARE: DR. DOUGLAS MAYER DAVID M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	01043622A	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	169380E	OTHER	IN	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396733101
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DOUGLAS MAYER DAVID M.D.

Provider Business Mailing Address
First Line	:	710 N NILES AVE
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46617-1924
Country	:	US
Telephone Number	:	574-647-1610
Fax Number	:	574-237-6069

Provider Business Practice Location Address
First Line	:	1815 E IRELAND RD
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46614-2845
Country	:	US
Telephone Number	:	574-647-1700
Fax Number	:	574-647-7572

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/06/2005
Last Update Date	:	04/01/2021

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