Provider Demographics
NPI:1942615497
Name:JACK FELICIANO MD, INC
Entity Type:Organization
Organization Name:JACK FELICIANO MD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ELPIDIO
Authorized Official - Middle Name:M
Authorized Official - Last Name:FELICIANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-385-4445
Mailing Address - Street 1:16531 STONEWOLF BLVD
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46060-1290
Mailing Address - Country:US
Mailing Address - Phone:765-284-0493
Mailing Address - Fax:765-284-2434
Practice Address - Street 1:2401 W UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-3428
Practice Address - Country:US
Practice Address - Phone:765-751-5253
Practice Address - Fax:765-282-8796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-24
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01056999207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty