Provider Demographics
NPI:1205034774
Name:JOSEPH A DEJOAN MD LLC
Entity Type:Organization
Organization Name:JOSEPH A DEJOAN MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:A
Authorized Official - Last Name:DEJOAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-462-0508
Mailing Address - Street 1:PO BOX 261
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46384-0261
Mailing Address - Country:US
Mailing Address - Phone:219-476-0352
Mailing Address - Fax:219-531-0859
Practice Address - Street 1:3301 CALUMET AVE
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2614
Practice Address - Country:US
Practice Address - Phone:219-462-0508
Practice Address - Fax:219-531-9032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-06
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01046269A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200887940Medicaid
IN000000526797OtherANTHEM BC/BS
IN253510Medicare PIN