Provider Demographics
NPI:1104825223
Name:MUNKEL, LAURA E (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:E
Last Name:MUNKEL
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 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:
Practice Address - Street 1:2120 RIETH BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-5843
Practice Address - Country:US
Practice Address - Phone:574-875-5126
Practice Address - Fax:574-875-1874
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01055084A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000200984OtherANTHEM BCBS
INP01316631OtherRR MEDICARE
IN200348260Medicaid
KY000000851204OtherBCBS BMG GOSHEN
INP01316631OtherRR MEDICARE
G80112Medicare UPIN
IN236040047Medicare PIN
IN000000870039OtherBCBS MEDPOINT CR6
IN080172615 RR MED#Medicare PIN