Healthcare Provider Details

I. General information

NPI: 1205189594
Provider Name (Legal Business Name): LAFAYETTE PAIN CARE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2012
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 PARK EAST BLVD STE B
LAFAYETTE IN
47905-0786
US

IV. Provider business mailing address

770 PARK EAST BLVD STE B
LAFAYETTE IN
47905-0786
US

V. Phone/Fax

Practice location:
  • Phone: 765-714-4344
  • Fax: 765-838-3200
Mailing address:
  • Phone: 765-714-4344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number01059790A
License Number StateIN

VIII. Authorized Official

Name: SHAZIA SIDDIQUI
Title or Position: OWNER
Credential: MD
Phone: 765-714-4344