Provider Demographics
NPI:1215989397
Name:KAMINSKY, MARC E (MD)
Entity type:Individual
Prefix:DR
First Name:MARC
Middle Name:E
Last Name:KAMINSKY
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 1:2200 RANDALLIA DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-4638
Mailing Address - Country:US
Mailing Address - Phone:260-373-4731
Mailing Address - Fax:
Practice Address - Street 1:3707 NEW VISION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845
Practice Address - Country:US
Practice Address - Phone:260-471-9466
Practice Address - Fax:260-484-5919
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN325012085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000092603OtherANTHEM
IN163520IMedicare ID - Type Unspecified
IN194930GMedicare ID - Type Unspecified
IN055740GMedicare ID - Type Unspecified
OHKA4111431Medicare ID - Type Unspecified
IN191150UMedicare ID - Type Unspecified
IN147380LMedicare ID - Type Unspecified
IN190320JMedicare ID - Type Unspecified
IN925240FMedicare ID - Type Unspecified
IND94462Medicare UPIN
IN924750DMedicare ID - Type Unspecified