Provider Demographics
NPI:1245218908
Name:FENOUGHTY, DEANNA M (MD)
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:M
Last Name:FENOUGHTY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1100 SOUTHFIELD DR
Mailing Address - Street 2:SUITE 1370
Mailing Address - City:PLAINFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46168-4498
Mailing Address - Country:US
Mailing Address - Phone:317-837-5571
Mailing Address - Fax:317-837-5580
Practice Address - Street 1:6911 E US HIGHWAY 36
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-8926
Practice Address - Country:US
Practice Address - Phone:317-272-8033
Practice Address - Fax:317-272-8044
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01056031A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100317590Medicaid
354590DDMedicare PIN
IN100317590Medicaid