Provider Demographics
NPI:1932158086
Name:FAST, DENNIS LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:LEE
Last Name:FAST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 J. H. WALKER DRIVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:PENDLETON
Mailing Address - State:IN
Mailing Address - Zip Code:46064
Mailing Address - Country:US
Mailing Address - Phone:765-778-7534
Mailing Address - Fax:765-778-7535
Practice Address - Street 1:350 JH WALKER DR
Practice Address - Street 2:SUITE 110
Practice Address - City:PENDLETON
Practice Address - State:IN
Practice Address - Zip Code:46064-8750
Practice Address - Country:US
Practice Address - Phone:765-778-7534
Practice Address - Fax:765-778-7535
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01028579207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INB29132Medicare UPIN
IN504820Medicare ID - Type Unspecified