Provider Demographics
NPI:1508858366
Name:MUSGRAVE, JOHN M (PSYD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:MUSGRAVE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6435 W JEFFERSON BLVD
Mailing Address - Street 2:PMB 145
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6203
Mailing Address - Country:US
Mailing Address - Phone:260-385-1646
Mailing Address - Fax:
Practice Address - Street 1:3470 STELLHORN RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-4630
Practice Address - Country:US
Practice Address - Phone:260-385-1646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041940A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000543924OtherANTHEM
IN200403270Medicaid
IN668340RMedicare PIN
INQ25236Medicare UPIN
IN200403270Medicaid
IN000000543924OtherANTHEM