Healthcare Provider Details

I. General information

NPI: 1548260680
Provider Name (Legal Business Name): LUIS A BARAJAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3170 WILLOWCREEK RD
PORTAGE IN
46368-4424
US

IV. Provider business mailing address

3170 WILLOWCREEK RD
PORTAGE IN
46368-4424
US

V. Phone/Fax

Practice location:
  • Phone: 219-764-7236
  • Fax: 219-764-7507
Mailing address:
  • Phone: 219-764-7236
  • Fax: 219-764-7507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number01050865A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01050865A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: