Provider Demographics
NPI:1386632644
Name:ESTEP, WANDA LEATHERMAN (MD)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:LEATHERMAN
Last Name:ESTEP
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 1:3743 LANDMARK DRIVE, STE 200
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-6633
Mailing Address - Country:US
Mailing Address - Phone:765-448-4511
Mailing Address - Fax:765-447-8375
Practice Address - Street 1:3774 BAYLEY DR STE A
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-8654
Practice Address - Country:US
Practice Address - Phone:765-807-8200
Practice Address - Fax:765-446-5155
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01058311A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000379525OtherANTHEM PROVIDER NUMBER
IN200463520Medicaid
IN11508177OtherCAQH
INI04361Medicare UPIN
INP00256939Medicare PIN
IN200463520Medicaid