Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207VX0000X | Obstetrician | 01020200A | IN |
NPI | 1174554554 |
---|---|
Provider Name | John Phillip Tyndall |
First Address | Fort Wayne, IN 46802-5257 |
Second Address | Fort Wayne, IN 46802-5257 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/07/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
C24159 | (02) | IN |