Provider Demographics
NPI:1043205800
Name:MAXWELL, DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:MAXWELL
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 1:8935 N MERIDIAN ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-5379
Mailing Address - Country:US
Mailing Address - Phone:317-564-2132
Mailing Address - Fax:317-574-4737
Practice Address - Street 1:1350 E COUNTY LINE RD
Practice Address - Street 2:SUITE L
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-0873
Practice Address - Country:US
Practice Address - Phone:317-865-8530
Practice Address - Fax:317-865-8539
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01022037A207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100099210Medicaid
IN100099210Medicaid
C24248Medicare UPIN
IN390003865Medicare PIN