Provider Demographics
NPI:1962482406
Name:SCHWARTZENTRUBER, DOUGLAS J (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:J
Last Name:SCHWARTZENTRUBER
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:STE 130 PROVIDER ENROLLMENT
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:317-963-0860
Mailing Address - Fax:
Practice Address - Street 1:535 BARNHILL DR
Practice Address - Street 2:RT 252
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5116
Practice Address - Country:US
Practice Address - Phone:317-944-0301
Practice Address - Fax:317-278-6523
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01031937174400000X
IN01031937A2086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200456350Medicaid
IN000000720155OtherANTHEM PIN
INH94725Medicare UPIN
INP01113498Medicare PIN
IN200456350Medicaid
INM400053983Medicare Oscar/Certification