Provider Demographics
NPI:1629248711
Name:O'BANNON, ASHLEY B (MD)
Entity Type:Individual
Prefix:DR
First Name:ASHLEY
Middle Name:B
Last Name:O'BANNON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ASHLEY
Other - Middle Name:BROOKE
Other - Last Name:O'BANNON LATINOVIC
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1160 JOLIET ST STE 204
Mailing Address - Street 2:
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311-2096
Mailing Address - Country:US
Mailing Address - Phone:800-799-2273
Mailing Address - Fax:219-319-5121
Practice Address - Street 1:1160 JOLIET ST STE 204
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-2096
Practice Address - Country:US
Practice Address - Phone:800-799-2273
Practice Address - Fax:219-319-5121
Is Sole Proprietor?:No
Enumeration Date:2008-03-05
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY40481207ZP0102X
IN01070948A207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ININ3131004OtherMEDICARE PTAN