Provider Demographics
NPI:1669587184
Name:FUQUA, JOHN S (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:S
Last Name:FUQUA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 1026
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1026
Mailing Address - Country:US
Mailing Address - Phone:317-274-1201
Mailing Address - Fax:317-278-9905
Practice Address - Street 1:705 RILEY HOSPITAL DR
Practice Address - Street 2:RI 5960
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5109
Practice Address - Country:US
Practice Address - Phone:317-944-3889
Practice Address - Fax:317-944-3882
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2021-02-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN010502422080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2655087Medicaid
IN200212230Medicaid
VT1021333Medicaid
KY64882921Medicaid
OH2655087Medicaid
IN200212230Medicaid