Healthcare Provider Details

I. General information

NPI: 1629075957
Provider Name (Legal Business Name): LINDA A MANSFIELD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date: 03/20/2006
Reactivation Date: 04/03/2006

III. Provider practice location address

1815 E IRELAND RD
SOUTH BEND IN
46614-2845
US

IV. Provider business mailing address

3245 HEALTH DR STE 100
GRANGER IN
46530-1380
US

V. Phone/Fax

Practice location:
  • Phone: 574-647-1700
  • Fax: 574-647-7572
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01069249A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number01069249A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: