Provider Demographics
NPI:1902816895
Name:MERTZ, MAX R (MD)
Entity Type:Individual
Prefix:DR
First Name:MAX
Middle Name:R
Last Name:MERTZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1814 CHARLTON CT STE A
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-6463
Mailing Address - Country:US
Mailing Address - Phone:574-533-4169
Mailing Address - Fax:574-534-8822
Practice Address - Street 1:1814 CHARLTON CT STE A
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-6463
Practice Address - Country:US
Practice Address - Phone:574-533-4169
Practice Address - Fax:574-534-8822
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01031930A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100113060Medicaid
IN100113060Medicaid
B28678Medicare UPIN