Provider Demographics
NPI:1285892752
Name:MASTBAUM ENDOCRINOLOGY
Entity type:Organization
Organization Name:MASTBAUM ENDOCRINOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JODIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HATTERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-969-7173
Mailing Address - Street 1:7900 W JEFFERSON BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4128
Mailing Address - Country:US
Mailing Address - Phone:260-969-7100
Mailing Address - Fax:260-969-7771
Practice Address - Street 1:7950 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4140
Practice Address - Country:US
Practice Address - Phone:260-435-7001
Practice Address - Fax:260-969-7101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-30
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01041346207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty