Provider Demographics
NPI:1356336788
Name:CASSIDY, KATHERINE L (MD)
Entity type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:L
Last Name:CASSIDY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:608 UNION CHAPEL RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-9357
Mailing Address - Country:US
Mailing Address - Phone:260-482-4440
Mailing Address - Fax:260-482-4442
Practice Address - Street 1:1316 E 7TH ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:IN
Practice Address - Zip Code:46706-2538
Practice Address - Country:US
Practice Address - Phone:260-373-4000
Practice Address - Fax:260-482-4442
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01054605A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000214697OtherANTHEM
OH2521284Medicaid
MI104874614Medicaid
930113729OtherRR MEDICARE
047840VVVOtherMEDICARE WPS/CMS
000000010974OtherMPLAN
IN200364960Medicaid
MI104874614Medicaid