Provider Demographics
NPI:1336193424
Name:POWELL, DAVID K (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:K
Last Name:POWELL
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 1:3707 NEW VISION DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1702
Mailing Address - Country:US
Mailing Address - Phone:260-471-9466
Mailing Address - Fax:
Practice Address - Street 1:3707 NEW VISION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1702
Practice Address - Country:US
Practice Address - Phone:260-471-9466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN020379062085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2100612Medicaid
IN000000092607OtherANTHEM
IN1712OtherPHP
IN100323460Medicaid
MI4074942100Medicaid
IN924750GMedicare ID - Type Unspecified
IN000000092607OtherANTHEM
IN163520NMedicare ID - Type Unspecified
OHPO4111651Medicare ID - Type Unspecified
IN194930LMedicare ID - Type Unspecified
MI4074942100Medicaid
OH2100612Medicaid
IN190320OMedicare ID - Type Unspecified
IN925240JMedicare ID - Type Unspecified