Provider Demographics
NPI:1497701890
Name:HABENICHT, ANN LAURA (DO)
Entity Type:Individual
Prefix:DR
First Name:ANN
Middle Name:LAURA
Last Name:HABENICHT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2510 COMMONS BLVD STE 240A
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45431-3820
Mailing Address - Country:US
Mailing Address - Phone:937-429-8620
Mailing Address - Fax:937-429-8629
Practice Address - Street 1:2510 COMMONS BLVD
Practice Address - Street 2:STE 240A
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45431
Practice Address - Country:US
Practice Address - Phone:937-429-8620
Practice Address - Fax:937-429-8629
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.013051204D00000X
IL036-066858207Q00000X
IN02002003A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201322900Medicaid
INP01588225OtherRAILROAD PTAN
IN266180606Medicare PIN
ILC45853Medicare UPIN