Provider Demographics
NPI:1831151869
Name:KIDDER, SHAWN E (DO)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:E
Last Name:KIDDER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 E DUPONT RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1545
Mailing Address - Country:US
Mailing Address - Phone:260-373-9700
Mailing Address - Fax:260-373-9740
Practice Address - Street 1:2235 DUBOIS DRIVE
Practice Address - Street 2:NULL
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-3212
Practice Address - Country:US
Practice Address - Phone:574-371-2625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ININ02001281207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200089430Medicaid
IN000000634019OtherANTHEM
IN000000664741OtherANTHEM
BK3333109OtherDEA
INM400017374Medicare PIN
1295250011Medicare ID - Type UnspecifiedDMZ
IN000000664741OtherANTHEM
G29124Medicare UPIN
IN069860A1Medicare PIN