Provider Demographics
NPI:1467687277
Name:CRAFT, LEAH DIANE (MD)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:DIANE
Last Name:CRAFT
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 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:574-237-6069
Practice Address - Street 1:2235 CLEVELAND RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46628-3529
Practice Address - Country:US
Practice Address - Phone:574-647-4530
Practice Address - Fax:574-647-2285
Is Sole Proprietor?:No
Enumeration Date:2009-05-22
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01068999A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201024230Medicaid
IN000000831444OtherANTHEM BCBS
IN000000845556OtherANTHEM BCBS
IN000000845557OtherANTHEM BCBS
IN000000845558OtherANTHEM BCBS
IN201024230Medicaid
IN162520006Medicare PIN
IN000000845557OtherANTHEM BCBS
IN178420009Medicare PIN
IN201024230Medicaid