Provider Demographics
NPI:1821059148
Name:DUNEVANT, DONALD SQUIRES (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:SQUIRES
Last Name:DUNEVANT
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 1:3630 WILLOWCREEK RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-5075
Mailing Address - Country:US
Mailing Address - Phone:219-759-1157
Mailing Address - Fax:
Practice Address - Street 1:3630 WILLOWCREEK RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-5075
Practice Address - Country:US
Practice Address - Phone:219-759-5791
Practice Address - Fax:219-759-3807
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01033863207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN080106826OtherRAILROAD
5251392OtherAETNA
IN000000522003OtherANTHEM
IN100188440AMedicaid
IN080106826OtherRAILROAD
INB29267Medicare UPIN