Provider Demographics
NPI:1114005402
Name:LABBAN, JOHN R (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:LABBAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 S WALKER ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2158
Mailing Address - Country:US
Mailing Address - Phone:812-334-0698
Mailing Address - Fax:812-334-0950
Practice Address - Street 1:650 S WALKER ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2158
Practice Address - Country:US
Practice Address - Phone:812-334-0698
Practice Address - Fax:812-334-0950
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01054787A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200340320Medicaid
IN000000321780OtherANTHEM PIN
IN61-1456354OtherTAX ID NUMBER
IN000000321780OtherANTHEM PIN
INF82078Medicare UPIN