Provider Demographics
NPI:1689645707
Name:BORMANN, JOHN LOUIS (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:LOUIS
Last Name:BORMANN
Suffix:
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:PO BOX 80070
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46898-0070
Mailing Address - Country:US
Mailing Address - Phone:260-432-1568
Mailing Address - Fax:260-432-4969
Practice Address - Street 1:5001 US HIGHWAY 30 W STE D
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46818-9701
Practice Address - Country:US
Practice Address - Phone:260-432-1568
Practice Address - Fax:260-432-4969
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010420162085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100333820Medicaid
OH0959155Medicaid
MI1689645707Medicaid
MIP00728971Medicare PIN
IN100333820Medicaid
IN981270OMedicare PIN
OH0959155Medicaid
IN300035928Medicare PIN
MI1689645707Medicaid
OHH187480Medicare PIN