Provider Demographics
NPI:1669487005
Name:DUPONT OB-GYN
Entity Type:Organization
Organization Name:DUPONT OB-GYN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROSEMARY
Authorized Official - Middle Name:
Authorized Official - Last Name:LEITCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD FACOG
Authorized Official - Phone:260-490-6260
Mailing Address - Street 1:11123 PARKVIEW PLAZA DR
Mailing Address - Street 2:SUITE 204
Mailing Address - City:FT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845
Mailing Address - Country:US
Mailing Address - Phone:260-490-6260
Mailing Address - Fax:260-490-6261
Practice Address - Street 1:11123 PARKVIEW PLAZA DR
Practice Address - Street 2:SUITE 204
Practice Address - City:FT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845
Practice Address - Country:US
Practice Address - Phone:260-490-6260
Practice Address - Fax:260-490-6261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01035629207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000093382OtherANTHEM BCBS
D69582Medicare UPIN
IN220520Medicare PIN
IN220520Medicare ID - Type Unspecified