Provider Demographics
NPI:1265431589
Name:DRAKE, JOHN E (DO)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:E
Last Name:DRAKE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3702 NEW VISION DR
Mailing Address - Street 2:BLDG B
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1703
Mailing Address - Country:US
Mailing Address - Phone:260-266-8210
Mailing Address - Fax:
Practice Address - Street 1:11123 PARKVIEW PLAZA DR
Practice Address - Street 2:SUITE 101
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1707
Practice Address - Country:US
Practice Address - Phone:260-422-7455
Practice Address - Fax:260-424-9356
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001845A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000595615OtherANTHEM
IN200493620Medicaid
INP00690557OtherRAILROAD MEDICARE
IN200129910Medicaid
IN000000511990OtherANTHEM PROVIDER ID# - WHC
IN3013250OtherOH MEDICAID
IN000000595615OtherANTHEM
IN3013250OtherOH MEDICAID
IN000000511990OtherANTHEM PROVIDER ID# - WHC
IN200129910Medicaid