Provider Demographics
NPI:1790767085
Name:FOLTYNIAK, MIROSLAW A (MD)
Entity Type:Individual
Prefix:DR
First Name:MIROSLAW
Middle Name:A
Last Name:FOLTYNIAK
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 1:1234 E. DUPONT RD.
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1545
Mailing Address - Country:US
Mailing Address - Phone:260-373-9700
Mailing Address - Fax:260-373-9740
Practice Address - Street 1:213 FAIRVIEW BLVD
Practice Address - Street 2:
Practice Address - City:KENDALLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46755-2988
Practice Address - Country:US
Practice Address - Phone:260-347-4900
Practice Address - Fax:260-347-4966
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-14
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01038834208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100190980Medicaid
INP00717118OtherMEDICAIRE RAILROAD
IN000000605424OtherANTHEM
INP00717118OtherMEDICAIRE RAILROAD
IN000000605424OtherANTHEM
IN070860B9Medicare PIN