Provider Demographics
NPI:1609876531
Name:DOUSE, DANDRAE (MD)
Entity Type:Individual
Prefix:
First Name:DANDRAE
Middle Name:
Last Name:DOUSE
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 1:401 N SAWYER RD
Practice Address - Street 2:
Practice Address - City:KENDALLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46755-2568
Practice Address - Country:US
Practice Address - Phone:260-347-8610
Practice Address - Fax:260-347-8617
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01028388A207L00000X
IN010283882083P0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1235OtherPHP
IN100322930AMedicaid
IN000000082078OtherANTHEM BC/BS
IN000000082078OtherANTHEM BC/BS
IN1235OtherPHP