Provider Demographics
NPI:1316990112
Name:OVERDAHL, MICHAEL C (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:OVERDAHL
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:260-266-6013
Mailing Address - Fax:
Practice Address - Street 1:11104 PARKVIEW CIRCLE DR
Practice Address - Street 2:SUITE 410
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1672
Practice Address - Country:US
Practice Address - Phone:260-266-5260
Practice Address - Fax:260-266-5269
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042341207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00685770OtherRR MEDICARE
IN200015210Medicaid
IN000000576774OtherANTHEM
IN000000670288OtherANTHEM
IN200015210Medicaid
IN925060TMedicare PIN
IN070860B6Medicare PIN
IN000000670288OtherANTHEM