Provider Demographics
NPI:1124135967
Name:DRAKE, FRED DUANE (MD)
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:DUANE
Last Name:DRAKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47807-4214
Mailing Address - Country:US
Mailing Address - Phone:812-242-3170
Mailing Address - Fax:812-235-3330
Practice Address - Street 1:1429 N 6TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47807-1037
Practice Address - Country:US
Practice Address - Phone:812-242-3170
Practice Address - Fax:812-235-3330
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01024937A207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
0182870OtherUS DEPT OF LABOR
IN100250540Medicaid
000000089620OtherANTHEM
040004682OtherRAILROAD MCARE PALAMETTO
IN192770YMedicare PIN
IN100250540Medicaid
0182870OtherUS DEPT OF LABOR
B29701Medicare UPIN
IN611880AMedicare PIN
IN607850HMedicare PIN
IN265130IIMedicare PIN