Provider Demographics
NPI:1174526917
Name:MCCALLISTER, ROBERT EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:EDWARD
Last Name:MCCALLISTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6920 PARKDALE PL
Mailing Address - Street 2:STE 210
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-5611
Mailing Address - Country:US
Mailing Address - Phone:317-299-3444
Mailing Address - Fax:317-299-8709
Practice Address - Street 1:6920 PARKDALE PL
Practice Address - Street 2:STE 210
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-5611
Practice Address - Country:US
Practice Address - Phone:317-299-3444
Practice Address - Fax:317-299-8709
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01030428207N00000X, 207NS0135X, 207NP0225X, 207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000087049OtherANTHEM PROVIDER NUMBER
IN351711573OtherTAX IDENTIFICATION NUMBER
IN070001836OtherRAILROAD MEDICARE
IN0004359769OtherAETNA
IN799290Medicare ID - Type Unspecified
IN0004359769OtherAETNA