Provider Demographics
NPI:1619064672
Name:FANG, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:FANG
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 1:8733 W 400 N
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-9330
Mailing Address - Country:US
Mailing Address - Phone:219-803-4145
Mailing Address - Fax:855-502-1900
Practice Address - Street 1:8733 W 400 N
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-9330
Practice Address - Country:US
Practice Address - Phone:219-803-4145
Practice Address - Fax:855-502-1900
Is Sole Proprietor?:No
Enumeration Date:2006-10-09
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIIN PROCESS207RG0300X
IN01065093207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000580377OtherANTHEM, BCBS
IN200920160Medicaid
IN000000580377OtherANTHEM, BCBS
IN200920160Medicaid