Provider Demographics
NPI:1255333951
Name:DALEY, PATRICK J (MD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:J
Last Name:DALEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 E DUPONT RD
Mailing Address - Street 2:SUITE3
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1545
Mailing Address - Country:US
Mailing Address - Phone:260-373-7875
Mailing Address - Fax:260-373-9705
Practice Address - Street 1:11108 PARKVIEW CIRCLE DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1730
Practice Address - Country:US
Practice Address - Phone:260-266-5700
Practice Address - Fax:260-266-5920
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01035420A207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN060070888OtherRR MEDICARE
OH0783488Medicaid
IN100085410Medicaid
IN000000641071OtherANTHEM
INP00807503OtherR.R. MEDICARE
OHDA0813648Medicare PIN
IN264380ZMedicare PIN
IN193580CMedicare PIN
IN060070888Medicare PIN
OHDA0813647Medicare PIN
IND94466Medicare UPIN
IN193590CMedicare PIN