Provider Demographics
NPI:1174795744
Name:LONERGAN, IAN MICHAEL (DO)
Entity type:Individual
Prefix:DR
First Name:IAN
Middle Name:MICHAEL
Last Name:LONERGAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19806-4047
Mailing Address - Country:US
Mailing Address - Phone:302-656-0214
Mailing Address - Fax:877-284-8933
Practice Address - Street 1:1600 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19806-4047
Practice Address - Country:US
Practice Address - Phone:302-656-0214
Practice Address - Fax:877-284-8933
Is Sole Proprietor?:No
Enumeration Date:2008-03-24
Last Update Date:2011-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101017079208200000X
DEC200088112086S0122X, 208D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
136323YABTOtherMEDICARE ID