Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207PP0204X | Pediatric Emergency Physician | 01070711A | IN |
N | 208000000X | Pediatrician | 35.090842 | OH |
NPI | 1699982553 |
---|---|
Provider Name | Cory Dale Showalter |
First Address | Indianapolis, IN 46219-4959 |
Second Address | Indianapolis, IN 46202-5109 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/05/2007 |
Last Update Date | 05/03/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
200912830 | (05) | IN |