Provider Demographics
NPI:1861492993
Name:DEDELOW, DOUGLAS C (DO)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:C
Last Name:DEDELOW
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9660 WICKER AVENUE
Mailing Address - Street 2:
Mailing Address - City:ST JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-9487
Mailing Address - Country:US
Mailing Address - Phone:219-226-2203
Mailing Address - Fax:219-226-2202
Practice Address - Street 1:1400 S LAKE PARK AVE
Practice Address - Street 2:STE 205
Practice Address - City:HOBART
Practice Address - State:IN
Practice Address - Zip Code:46342-6790
Practice Address - Country:US
Practice Address - Phone:219-942-8620
Practice Address - Fax:219-942-6356
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001822A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200127880Medicaid
IN256700AOtherMEDICARE PTAN
IN200127880Medicaid
G47010Medicare UPIN