Provider Demographics
NPI:1326070152
Name:SQUIRES, JEFFREY P (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:P
Last Name:SQUIRES
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 1:3240B MALLARD COVE LN
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-2883
Mailing Address - Country:US
Mailing Address - Phone:260-432-5867
Mailing Address - Fax:260-436-9013
Practice Address - Street 1:7950 W JEFFERSON BLVD
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:260-435-7154
Practice Address - Fax:260-435-7633
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1028175207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
220011660OtherRAILROAD
IN100348010Medicaid
IN056680HMedicare ID - Type Unspecified
IN200430BMedicare ID - Type Unspecified
220011660OtherRAILROAD