Provider Demographics
NPI:1881664589
Name:ADRIAN, DWAYNE C (MD)
Entity Type:Individual
Prefix:
First Name:DWAYNE
Middle Name:C
Last Name:ADRIAN
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 1:1200 W WHITE RIVER BLVD
Mailing Address - Street 2:RCS PROVIDER ENROLLMENT
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-4988
Mailing Address - Country:US
Mailing Address - Phone:765-254-4009
Mailing Address - Fax:
Practice Address - Street 1:2701 W NORTH ST
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-3415
Practice Address - Country:US
Practice Address - Phone:765-281-6920
Practice Address - Fax:765-284-6151
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01034541A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100106750EMedicaid
IN100106750AMedicaid
INP00930236Medicare PIN
INP00951255Medicare PIN
INM400022489Medicare PIN
INM400031715Medicare PIN
IN100106750AMedicaid