Provider Demographics
NPI:1720068646
Name:PHILLIPS, DONALD MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:MICHAEL
Last Name:PHILLIPS
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 1:1356 S LAKE PARK AVE
Mailing Address - Street 2:
Mailing Address - City:HOBART
Mailing Address - State:IN
Mailing Address - Zip Code:46342-5964
Mailing Address - Country:US
Mailing Address - Phone:219-942-8518
Mailing Address - Fax:219-947-2751
Practice Address - Street 1:1356 S LAKE PARK AVE
Practice Address - Street 2:
Practice Address - City:HOBART
Practice Address - State:IN
Practice Address - Zip Code:46342-5964
Practice Address - Country:US
Practice Address - Phone:219-942-8518
Practice Address - Fax:219-947-2751
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-18
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01020846A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000086604OtherBLUE CROSS BLUE SHIELD
IN100159850AMedicaid
IN011164281Medicare PIN
IN100159850AMedicaid
IN471340Medicare PIN