Healthcare Provider Details

I. General information

NPI: 1073899753
Provider Name (Legal Business Name): LAFAYETTE WOMENS HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2011
Last Update Date: 10/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3774 BAYLEY DR SUITE B
LAFAYETTE IN
47905-8651
US

IV. Provider business mailing address

3774 BAYLEY DR SUITE B
LAFAYETTE IN
47905-8651
US

V. Phone/Fax

Practice location:
  • Phone: 765-807-2280
  • Fax: 765-807-2281
Mailing address:
  • Phone: 765-807-2280
  • Fax: 765-807-2281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERT IDESON
Title or Position: ADMINISTRATOR
Credential:
Phone: 765-428-5888