Provider Demographics
NPI:1639229156
Name:YANIZ, ADOLPH RALPH (MD)
Entity Type:Individual
Prefix:DR
First Name:ADOLPH
Middle Name:RALPH
Last Name:YANIZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5490 BROADWAY
Mailing Address - Street 2:SUITE 105
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-1675
Mailing Address - Country:US
Mailing Address - Phone:219-884-3210
Mailing Address - Fax:219-884-3244
Practice Address - Street 1:5490 BROADWAY
Practice Address - Street 2:SUITE 105
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-1675
Practice Address - Country:US
Practice Address - Phone:219-884-3210
Practice Address - Fax:219-884-3244
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2010-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010380025A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000088069OtherBLUE CROSS BLUE SHIELD
IN100201270AMedicaid
IN100201270AMedicaid
IN408190Medicare ID - Type Unspecified