Provider Demographics
NPI:1376758524
Name:DEDELOW, JEFFREY ALAN (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ALAN
Last Name:DEDELOW
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:514 W 2ND ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2316
Practice Address - Country:US
Practice Address - Phone:812-353-3719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01069197A207RH0002X, 2085R0202X, 207RH0002X
MI43010892582085N0904X, 2085R0202X
LAMD0267412085R0202X
OH35.1220172085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1049913Medicaid
MS04377066Medicaid
IN201015030Medicaid
INP01119545OtherRAILROAD MEDICARE
MI5186380Medicaid
OH0090190Medicaid
INM400072379Medicare PIN
MS04377066Medicaid
LA4N0877061Medicare PIN
LA4N087Medicare PIN