MEDICARE: WANDA LEATHERMAN ESTEP M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	01058311A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000379525	OTHER	IN	ANTHEM PROVIDER NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	11508177	OTHER	IN	CAQH

General Provider Information

NPI Number	:	1386632644
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WANDA LEATHERMAN ESTEP M.D.

Provider Business Mailing Address
First Line	:	3743 LANDMARK DRIVE, STE 200
Second Line	:
City	:	LAFAYETTE
State	:	IN
Zip	:	47905-6633
Country	:	US
Telephone Number	:	765-448-4511
Fax Number	:	765-447-8375

Provider Business Practice Location Address
First Line	:	3774 BAYLEY DR STE A
Second Line	:
City	:	LAFAYETTE
State	:	IN
Zip	:	47905-8654
Country	:	US
Telephone Number	:	765-807-8200
Fax Number	:	765-446-5155

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/11/2005
Last Update Date	:	11/03/2023

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