Provider Demographics
NPI:1326067000
Name:MANSFIELD, DENNIS DALE (MD)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:DALE
Last Name:MANSFIELD
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 1:7950 W JEFFERSON BLVD STE 2121
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4140
Mailing Address - Country:US
Mailing Address - Phone:260-435-7937
Mailing Address - Fax:260-407-8004
Practice Address - Street 1:7950 W JEFFERSON BLVD STE 2121
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4140
Practice Address - Country:US
Practice Address - Phone:260-435-7937
Practice Address - Fax:260-407-8004
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10135447A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN178650GMedicare ID - Type Unspecified
IN142520OMedicare ID - Type Unspecified
IN138420OOMedicare ID - Type Unspecified
E03753Medicare UPIN