Provider Demographics
NPI:1790788255
Name:BOWDITCH, DALLIS MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:DALLIS
Middle Name:MARK
Last Name:BOWDITCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1201 MICHIGAN AVE
Mailing Address - Street 2:SUITE 140
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-1580
Mailing Address - Country:US
Mailing Address - Phone:574-753-1462
Mailing Address - Fax:574-753-1465
Practice Address - Street 1:1201 MICHIGAN AVE
Practice Address - Street 2:SUITE 140
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-1580
Practice Address - Country:US
Practice Address - Phone:574-753-1462
Practice Address - Fax:574-753-1465
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01032465A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN4216390OtherAETNA ID
IN100070810Medicaid
000000546802OtherANTHEM BLUE CROSS
IN6148784003OtherCIGNA ID
080096741OtherMEDICARE RAILROAD
112810COtherOLD MEDICARE ID #
IN6148784003OtherCIGNA ID
B28389Medicare UPIN