Provider Demographics
NPI:1659373066
Name:DOLORESCO, FRED II (MD)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:
Last Name:DOLORESCO
Suffix:II
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 1:1234 E DUPONT RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1545
Mailing Address - Country:US
Mailing Address - Phone:260-373-7875
Mailing Address - Fax:260-373-9705
Practice Address - Street 1:11108 PARKVIEW CIRCLE DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1730
Practice Address - Country:US
Practice Address - Phone:260-266-5700
Practice Address - Fax:260-266-5920
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01033928A207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0568952Medicaid
IN060070575OtherRR MEDICARE
IN100146050Medicaid
INP00793604OtherR.R. MEDICARE
IN000000641073OtherANTHEM
IN000000641073OtherANTHEM
IN100146050Medicaid
INP00793604OtherR.R. MEDICARE
INA01457Medicare UPIN
OH0568952Medicaid