Healthcare Provider Details

I. General information

NPI: 1134189053
Provider Name (Legal Business Name): LINDA HIGGINBOTHAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 06/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 N EDDY ST
SOUTH BEND IN
46617-2808
US

IV. Provider business mailing address

211 N EDDY ST
SOUTH BEND IN
46617-2808
US

V. Phone/Fax

Practice location:
  • Phone: 574-237-9231
  • Fax: 574-204-6355
Mailing address:
  • Phone: 574-237-9231
  • Fax: 574-204-6355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberLH044277
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number01069131A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberG53699
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: