Healthcare Provider Details

I. General information

NPI: 1003818626
Provider Name (Legal Business Name): LAWRENCE JOHN BORN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 10/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8424 NAAB RD #3-J
INDIANAPOLIS IN
46260-5918
US

IV. Provider business mailing address

8424 NAAB RD #3-J
INDIANAPOLIS IN
46260-5918
US

V. Phone/Fax

Practice location:
  • Phone: 317-872-7396
  • Fax: 317-879-8328
Mailing address:
  • Phone: 317-872-7396
  • Fax: 317-879-8328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number01037740A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: