Provider Demographics
NPI:1508891276
Name:YOUNGBLOOD, LISA A (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:YOUNGBLOOD
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 1:690 W NORTHFIELD DR STE 200
Mailing Address - Street 2:
Mailing Address - City:BROWNSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:46112-7504
Mailing Address - Country:US
Mailing Address - Phone:317-779-1466
Mailing Address - Fax:
Practice Address - Street 1:690 W NORTHFIELD DR STE 200
Practice Address - Street 2:
Practice Address - City:BROWNSBURG
Practice Address - State:IN
Practice Address - Zip Code:46112-7504
Practice Address - Country:US
Practice Address - Phone:317-779-1466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042167207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100463820Medicaid
IN234840AMedicare PIN
IN264430TTMedicare PIN
INF76097Medicare UPIN
INP00868377Medicare PIN