Provider Demographics
NPI:1679688295
Name:MORAN, DAVID JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JOHN
Last Name:MORAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 CAREW ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-4765
Mailing Address - Country:US
Mailing Address - Phone:260-373-9728
Mailing Address - Fax:260-373-9740
Practice Address - Street 1:5104 N CLINTON ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-5720
Practice Address - Country:US
Practice Address - Phone:260-422-2481
Practice Address - Fax:260-969-3067
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01044168A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00698427OtherMEDICARE RR
IN200150750Medicaid
IN000000595587OtherANTHEM
IN259060TMedicare PIN
INP00698427OtherMEDICARE RR
IN200150750Medicaid