Provider Demographics
NPI:1134189053
Name:HIGGINBOTHAM, LINDA (MD)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:HIGGINBOTHAM
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 1:211 N EDDY ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2808
Mailing Address - Country:US
Mailing Address - Phone:574-237-9231
Mailing Address - Fax:574-204-6355
Practice Address - Street 1:211 N EDDY ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2808
Practice Address - Country:US
Practice Address - Phone:574-237-9231
Practice Address - Fax:574-204-6355
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MILH044277207N00000X
IN01069131A207N00000X
CAG53699207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000699107OtherANTHEM PROVIDER NUMBER
IN000000733964OtherANTHEM BCBS PIN
MI50842OtherOMNICARE HEALTH PLAN
MI3093970Medicaid
MI070H263730OtherBCBSM/BCN
MI447756OtherAETNA
MI142732OtherGREAT LAKES HELATH PLAN
IN201035670Medicaid
MI070H263730OtherBCBSM/BCN
MI142732OtherGREAT LAKES HELATH PLAN
MI3093970Medicaid