Provider Demographics
NPI:1225290711
Name:FAHLER, DONALD
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:
Last Name:FAHLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 W WHITE RIVER BLVD
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-4988
Mailing Address - Country:US
Mailing Address - Phone:877-668-5621
Mailing Address - Fax:
Practice Address - Street 1:253 SAGAMORE PKWY W
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-1501
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:765-448-7606
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.013903208000000X
IN01067769A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200980950Medicaid
IN000000670768OtherANTHEM PROVIDER NUMBER
INM400018303Medicare PIN