Provider Demographics
NPI:1821101957
Name:DANDRIDGE, CLAUDETTE R (MD)
Entity Type:Individual
Prefix:MS
First Name:CLAUDETTE
Middle Name:R
Last Name:DANDRIDGE
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:PO BOX 1430
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-9230
Mailing Address - Country:US
Mailing Address - Phone:219-763-8112
Mailing Address - Fax:219-764-3251
Practice Address - Street 1:6920 INDIANAPOLIS BLVD
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:IN
Practice Address - Zip Code:46324-2206
Practice Address - Country:US
Practice Address - Phone:219-763-8112
Practice Address - Fax:219-764-3251
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036379174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100215560Medicaid
IN000000096837OtherANTHEM PROVIDER ID NO
INB29337Medicare UPIN