Provider Demographics
NPI:1386733525
Name:ACKERMAN, DWAYNE ALLEN (DC)
Entity type:Individual
Prefix:
First Name:DWAYNE
Middle Name:ALLEN
Last Name:ACKERMAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 123
Mailing Address - Street 2:
Mailing Address - City:WADESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47638-0123
Mailing Address - Country:US
Mailing Address - Phone:812-673-4947
Mailing Address - Fax:812-673-4846
Practice Address - Street 1:7125 HWY 66
Practice Address - Street 2:
Practice Address - City:WADESVILLE
Practice Address - State:IN
Practice Address - Zip Code:47638-0123
Practice Address - Country:US
Practice Address - Phone:812-673-4947
Practice Address - Fax:812-673-4846
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001203A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000088512OtherANTHEM BC & BS
660740Medicare PIN