Provider Demographics
NPI:1720094584
Name:BANGURA, LUELLA (MD)
Entity Type:Individual
Prefix:DR
First Name:LUELLA
Middle Name:
Last Name:BANGURA
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 1:13 S BROOKFIELD DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-7658
Mailing Address - Country:US
Mailing Address - Phone:765-447-7941
Mailing Address - Fax:765-447-4206
Practice Address - Street 1:5 EXECUTIVE DR STE G
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4867
Practice Address - Country:US
Practice Address - Phone:765-448-4646
Practice Address - Fax:765-448-4791
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01045193A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200421310Medicaid
IN000000520469OtherANTHEM PROVIDER PIN
IN000000520469OtherANTHEM PROVIDER PIN
INF88354Medicare UPIN
IN216380AMedicare ID - Type Unspecified
IN815490XXXMedicare PIN