Provider Demographics
NPI:1285710186
Name:DOOLAN, PATRICK (MD)
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:DOOLAN
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 1:504 W CAMP ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IN
Mailing Address - Zip Code:46052-1647
Mailing Address - Country:US
Mailing Address - Phone:765-482-7005
Mailing Address - Fax:765-483-3021
Practice Address - Street 1:504 W CAMP ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:IN
Practice Address - Zip Code:46052-1647
Practice Address - Country:US
Practice Address - Phone:765-482-7005
Practice Address - Fax:765-483-3021
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01037742207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100063550Medicaid
INE03649Medicare UPIN
080159317Medicare PIN
IN100063550Medicaid