Provider Demographics
NPI:1164492245
Name:FIRESTONE, FRANKLIN (MD)
Entity Type:Individual
Prefix:
First Name:FRANKLIN
Middle Name:
Last Name:FIRESTONE
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:PO BOX 1690
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46352-1690
Mailing Address - Country:US
Mailing Address - Phone:219-326-2312
Mailing Address - Fax:219-326-2584
Practice Address - Street 1:3777 NORTH FRONTAGE ROAD
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-7694
Practice Address - Country:US
Practice Address - Phone:219-879-6021
Practice Address - Fax:219-879-6365
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01035507A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM400038801OtherMEDICARE PTAN
IN100085090Medicaid
IN000000704703OtherANTHEM
B29059Medicare UPIN