Provider Demographics
NPI:1669440418
Name:CROGHAN, JAYNE (MD)
Entity Type:Individual
Prefix:
First Name:JAYNE
Middle Name:
Last Name:CROGHAN
Suffix:
Gender:F
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:PO BOX 3299
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89702-3299
Mailing Address - Country:US
Mailing Address - Phone:317-782-1577
Mailing Address - Fax:317-780-5538
Practice Address - Street 1:3834 S EMERSON AVE
Practice Address - Street 2:BLDG C STE 100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46203
Practice Address - Country:US
Practice Address - Phone:317-782-1577
Practice Address - Fax:317-780-5538
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01029812A207P00000X, 207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200544630AMedicaid
IN715320LLMedicare PIN
IN200544630AMedicaid