Provider Demographics
NPI:1407862212
Name:BJONBACK, CAROLINE E (MD)
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:E
Last Name:BJONBACK
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 1690
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46352-1690
Mailing Address - Country:US
Mailing Address - Phone:219-326-2312
Mailing Address - Fax:219-326-2584
Practice Address - Street 1:400 LEGACY PLZ W
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-5296
Practice Address - Country:US
Practice Address - Phone:219-326-1775
Practice Address - Fax:219-326-1951
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01044334207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN00000079447OtherANTHEM, BCBS
IN200073080Medicaid
IN200073080Medicaid
ING20259Medicare UPIN