Provider Demographics
NPI:1629255880
Name:PERRY, LATOYA JEANEEN (MD)
Entity Type:Individual
Prefix:DR
First Name:LATOYA
Middle Name:JEANEEN
Last Name:PERRY
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 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 NAVARRE PL STE 4470
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1168
Practice Address - Country:US
Practice Address - Phone:574-647-4230
Practice Address - Fax:574-647-4235
Is Sole Proprietor?:No
Enumeration Date:2008-01-29
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01083188A207V00000X, 207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300033075Medicaid
IN300033075Medicaid
ILF400152681OtherMEDICARE PTAN (INDIVIDUAL)
IL036135406OtherMEDICAID PTAN
IL206147OtherMEDICARE PTAN (GROUP)