Provider Demographics
NPI:1073892428
Name:BLACKFORD, LAURA ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ELIZABETH
Last Name:BLACKFORD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6309
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46660-6309
Mailing Address - Country:US
Mailing Address - Phone:574-335-8700
Mailing Address - Fax:574-335-0760
Practice Address - Street 1:2349 LAKE AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-7835
Practice Address - Country:US
Practice Address - Phone:574-948-5100
Practice Address - Fax:574-948-5499
Is Sole Proprietor?:No
Enumeration Date:2011-08-16
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY008-T1207Q00000X
IN01074430207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000896281OtherBCBS
INP01504489OtherRR MEDICARE
IN201243260Medicaid
IN201243260Medicaid