Provider Demographics
NPI:1033392808
Name:DESTRY W LAMBERT MD INC
Entity Type:Organization
Organization Name:DESTRY W LAMBERT MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFC MGN
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINNIE
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-675-7601
Mailing Address - Street 1:403 FAIRGROUNDS RD
Mailing Address - Street 2:
Mailing Address - City:TIPTON
Mailing Address - State:IN
Mailing Address - Zip Code:46072-9596
Mailing Address - Country:US
Mailing Address - Phone:765-675-7601
Mailing Address - Fax:765-675-8052
Practice Address - Street 1:403 FAIRGROUNDS RD
Practice Address - Street 2:
Practice Address - City:TIPTON
Practice Address - State:IN
Practice Address - Zip Code:46072-9596
Practice Address - Country:US
Practice Address - Phone:765-675-7601
Practice Address - Fax:765-675-8052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-14
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01024399261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100233710Medicaid
IN100233710Medicaid
IND70777Medicare UPIN