Provider Demographics
NPI:1326040395
Name:FALLON, JOHN H (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:H
Last Name:FALLON
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 1:10021 DUPONT CIRCLE CT
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1604
Mailing Address - Country:US
Mailing Address - Phone:260-426-8117
Mailing Address - Fax:260-420-0817
Practice Address - Street 1:10021 DUPONT CIRCLE CT
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1604
Practice Address - Country:US
Practice Address - Phone:260-426-8117
Practice Address - Fax:260-420-0817
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01035289A207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100261520AMedicaid
IN040014980OtherRR MEDICARE
OH0827850Medicaid
IN151060BMedicare PIN
IN100261520AMedicaid
IN047930JJMedicare PIN