Provider Demographics
NPI:1922063189
Name:ADDO, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:ADDO
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 1:2622 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-5410
Mailing Address - Country:US
Mailing Address - Phone:260-425-3100
Mailing Address - Fax:260-425-3604
Practice Address - Street 1:2622 LAKE AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5410
Practice Address - Country:US
Practice Address - Phone:260-425-3100
Practice Address - Fax:260-425-3604
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01044290A208D00000X
IN01044290207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200068810Medicaid
IN150640CMedicare PIN
IN200068810Medicaid