Provider Demographics
NPI:1407947807
Name:BLANKENSHIP, LARRY L JR (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:L
Last Name:BLANKENSHIP
Suffix:JR
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 1:1210 MEDICAL ARTS BLVD STE 114
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46011-3442
Mailing Address - Country:US
Mailing Address - Phone:765-298-4545
Mailing Address - Fax:765-298-4945
Practice Address - Street 1:1210 MEDICAL ARTS BLVD STE 114
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46011-3442
Practice Address - Country:US
Practice Address - Phone:765-298-4545
Practice Address - Fax:765-298-4945
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01043570A2084N0600X, 2084S0012X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
130012612OtherRAILROAD MEDICARE
IN200029250AMedicaid
IN000000086592OtherANTHEM BLUE CROSS & BLUE
IN000000086592OtherANTHEM BLUE CROSS & BLUE
E95406Medicare UPIN
IN200029250AMedicaid