Provider Demographics
NPI:1245502947
Name:CLAUDETTE DANDRIDGE M.D.
Entity type:Organization
Organization Name:CLAUDETTE DANDRIDGE M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CLAUDETTE
Authorized Official - Middle Name:R
Authorized Official - Last Name:DANDRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-882-0262
Mailing Address - Street 1:720 W 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46402-1808
Mailing Address - Country:US
Mailing Address - Phone:219-882-0262
Mailing Address - Fax:219-882-0515
Practice Address - Street 1:720 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46402-1808
Practice Address - Country:US
Practice Address - Phone:219-882-0262
Practice Address - Fax:219-882-0515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-27
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036379261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care