Healthcare Provider Details

I. General information

NPI: 1407862212
Provider Name (Legal Business Name): CAROLINE E BJONBACK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 12/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 LEGACY PLZ W
LA PORTE IN
46350-5296
US

IV. Provider business mailing address

PO BOX 1690
LA PORTE IN
46352-1690
US

V. Phone/Fax

Practice location:
  • Phone: 219-326-1775
  • Fax: 219-326-1951
Mailing address:
  • Phone: 219-326-2312
  • Fax: 219-326-2584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01044334
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: