Provider Demographics
NPI:1376510958
Name:VENNEKOTTER, DONALD JUDE (MD)
Entity type:Individual
Prefix:MR
First Name:DONALD
Middle Name:JUDE
Last Name:VENNEKOTTER
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 1:721 W 13TH ST
Mailing Address - Street 2:SUITE 220
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47546-1817
Mailing Address - Country:US
Mailing Address - Phone:812-482-4494
Mailing Address - Fax:812-482-4499
Practice Address - Street 1:721 W 13TH ST
Practice Address - Street 2:SUITE 220
Practice Address - City:JASPER
Practice Address - State:IN
Practice Address - Zip Code:47546-1817
Practice Address - Country:US
Practice Address - Phone:812-482-4494
Practice Address - Fax:812-482-4499
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01041321208600000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN00000022029OtherATHEM BLUE CROSS
IN000000220292OtherANTHEM
IN200002870Medicaid
IN000000220292OtherANTHEM
IN212760DMedicare ID - Type Unspecified
INF45859Medicare UPIN