Provider Demographics
NPI:1235103615
Name:BLANKENHORN, PETER B (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:B
Last Name:BLANKENHORN
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 1:2010 W 86TH ST
Mailing Address - Street 2:STE. 200
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-1947
Mailing Address - Country:US
Mailing Address - Phone:317-872-6551
Mailing Address - Fax:317-875-7329
Practice Address - Street 1:2010 W 86TH ST
Practice Address - Street 2:STE. 200
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1947
Practice Address - Country:US
Practice Address - Phone:317-872-6551
Practice Address - Fax:317-875-7329
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036712A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100068270Medicaid
INA15387Medicare UPIN
IN898190F6Medicare ID - Type Unspecified
INM400014994Medicare PIN