Provider Demographics
NPI:1003946328
Name:DENNIS, ANTHONY D (MD)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:D
Last Name:DENNIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11635 COLDWATER RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1256
Mailing Address - Country:US
Mailing Address - Phone:260-637-1661
Mailing Address - Fax:260-637-1601
Practice Address - Street 1:11635 COLDWATER RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1256
Practice Address - Country:US
Practice Address - Phone:260-637-1661
Practice Address - Fax:260-637-1601
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01062780A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G99296Medicare UPIN
IN668020B2Medicare PIN
IN192240KKKKMedicare PIN
INP00413739Medicare PIN
IN090430A5Medicare PIN
IN668040B3Medicare PIN
IN668030B2Medicare PIN