Provider Demographics
NPI:1336126895
Name:MOOIBROEK, STEVEN J (MD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:J
Last Name:MOOIBROEK
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11123 PARKVIEW PLAZA DR STE 106
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1707
Practice Address - Country:US
Practice Address - Phone:260-672-6550
Practice Address - Fax:260-672-6565
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01054479A208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000196870OtherANTHEM
IN200330780Medicaid
7559229OtherAETNA
IN12184OtherPHYSICIANS HEALTH PLAN
IN3937240024OtherMEDICARE DMEPOS
00002092742 02OtherUNITED
IN069860AAMedicare ID - Type Unspecified
7559229OtherAETNA
IN12184OtherPHYSICIANS HEALTH PLAN