Provider Demographics
NPI:1528024783
Name:LOE, WILLIAM A JR (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:A
Last Name:LOE
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:3702 NEW VISION DR BLDG B
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11123 PARKVIEW PLAZA DR STE 200
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845
Practice Address - Country:US
Practice Address - Phone:260-425-6100
Practice Address - Fax:260-425-6105
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA0165092086S0120X
TN622962086S0120X
IN01079883A2086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1330035Medicaid
COCOA102589Medicare PIN
LAE64650Medicare UPIN
LA1330035Medicaid