Provider Demographics
NPI:1457349201
Name:DICKMEYER, MARK C (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:DICKMEYER
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:
Mailing Address - Fax:
Practice Address - Street 1:1818 CAREW ST STE 120
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4764
Practice Address - Country:US
Practice Address - Phone:260-425-6200
Practice Address - Fax:260-425-6205
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2022-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01063502A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30530200Medicaid
WI763OtherDEAN HEALTH INSURANCE
IN000000777143OtherANTHEM
IN200857350Medicaid
INM400057540Medicare PIN
WI080181487Medicare ID - Type UnspecifiedRAILROAD MEDICARE
WI763OtherDEAN HEALTH INSURANCE
IN200857350Medicaid