Provider Demographics
NPI:1356423859
Name:PAQUETTE, IAN M (MD)
Entity type:Individual
Prefix:DR
First Name:IAN
Middle Name:M
Last Name:PAQUETTE
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:PO BOX 636256 CENTRAL CREDENTIALING
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6256
Mailing Address - Country:US
Mailing Address - Phone:513-585-5506
Mailing Address - Fax:513-585-5511
Practice Address - Street 1:2123 AUBURN AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2906
Practice Address - Country:US
Practice Address - Phone:513-929-0104
Practice Address - Fax:513-929-4369
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH13264208600000X
OH35.097012208600000X, 208C00000X
MN53132208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201020980Medicaid
KY7100160520Medicaid
OH3141808Medicaid
OH3141808Medicaid