Provider Demographics
NPI:1750382438
Name:INGALLS, CONNIE S (MD)
Entity type:Individual
Prefix:DR
First Name:CONNIE
Middle Name:S
Last Name:INGALLS
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:920 W MARKET ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-2773
Mailing Address - Country:US
Mailing Address - Phone:419-227-7770
Mailing Address - Fax:419-229-8258
Practice Address - Street 1:920 W MARKET ST
Practice Address - Street 2:SUITE 210
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45805-2773
Practice Address - Country:US
Practice Address - Phone:419-227-7770
Practice Address - Fax:419-229-8258
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-03
Last Update Date:2012-05-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OH35073360I207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2030546Medicaid
OH311593871OtherTAX ID NUMBER
OH2030546Medicaid
OH080118739Medicare PIN
OHG76255Medicare UPIN