Provider Demographics
NPI:1013919422
Name:CHASTAIN, HOLLACE D (MD)
Entity type:Individual
Prefix:
First Name:HOLLACE
Middle Name:D
Last Name:CHASTAIN
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11108 PARKVIEW CIRCLE DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1730
Practice Address - Country:US
Practice Address - Phone:260-266-5700
Practice Address - Fax:260-266-5920
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01039775A207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000641068OtherANTHEM
IN060070569OtherRR MEDICARE
IN200322020Medicaid
OH2232319Medicaid
INP00786816OtherR.R. MEDICARE
INH32747Medicare UPIN
IN264380KMedicare PIN
IN193590UMedicare PIN
IN060070569OtherRR MEDICARE
IN060070569Medicare PIN