Provider Demographics
NPI:1033120969
Name:SEVERINAC, ROBERT NICHOLAS (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:NICHOLAS
Last Name:SEVERINAC
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 1:10020 DUPONT CIRCLE CT
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1620
Mailing Address - Country:US
Mailing Address - Phone:260-489-0099
Mailing Address - Fax:260-489-0066
Practice Address - Street 1:10020 DUPONT CIRCLE CT
Practice Address - Street 2:SUITE 100
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1620
Practice Address - Country:US
Practice Address - Phone:260-489-0099
Practice Address - Fax:260-489-0066
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01043388A208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
INF82490Medicare UPIN