Provider Demographics
NPI:1821058363
Name:VANCUREN, JEFFREY A (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:A
Last Name:VANCUREN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 MICHIGAN AVE
Mailing Address - Street 2:SUITE 115
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-1593
Mailing Address - Country:US
Mailing Address - Phone:574-722-3566
Mailing Address - Fax:574-753-6118
Practice Address - Street 1:1025 MICHIGAN AVE
Practice Address - Street 2:SUITE 115
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-1593
Practice Address - Country:US
Practice Address - Phone:574-722-3566
Practice Address - Fax:574-753-6118
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01046838207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200124110AMedicaid
IN200124110Medicaid
IN000000524942OtherANTHEM BLUE CROSS
IN000000524942OtherANTHEM BLUE CROSS
IN111880EMedicare ID - Type Unspecified
IN200124110Medicaid