Provider Demographics
NPI:1205821659
Name:WARRENER, GERALD G (MD)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:G
Last Name:WARRENER
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:104 NICHOLAS PL
Practice Address - Street 2:
Practice Address - City:AVILLA
Practice Address - State:IN
Practice Address - Zip Code:46710-0069
Practice Address - Country:US
Practice Address - Phone:260-897-2520
Practice Address - Fax:260-897-3650
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01027892207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN10054680AMedicaid
INP00632884OtherMEDICARE RAILROAD
IN000000365007OtherANTHEM
IN000000570557OtherANTHEM
IN000000570557OtherANTHEM
IN069860MMMMMedicare PIN
IN000000365007OtherANTHEM
IN070860PMedicare UPIN