Provider Demographics
NPI:1669463089
Name:JAKACKI, PETER A (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:A
Last Name:JAKACKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6920 POINTE INVERNESS WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7934
Mailing Address - Country:US
Mailing Address - Phone:260-479-3516
Mailing Address - Fax:260-479-3520
Practice Address - Street 1:2512 E DUPONT RD
Practice Address - Street 2:SUITE 210
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1609
Practice Address - Country:US
Practice Address - Phone:260-497-0084
Practice Address - Fax:260-484-2859
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01052452A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000183064OtherBLUE CROSS BLUE SHIELD
IN200347770Medicaid
INP00989023OtherRAILROAD MEDICARE
000000183064OtherBLUE CROSS BLUE SHIELD
INP00989023OtherRAILROAD MEDICARE
IN080168211OtherRAILROAD MEDICARE
000000183064OtherBLUE CROSS BLUE SHIELD
000000001318OtherMPLAN
3147OtherPHYSICIANS HEALTH PLAN
IN925530FMedicare PIN