Provider Demographics
NPI:1831753540
Name:LANKFORD, JAY BRADLEY (DO)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:BRADLEY
Last Name:LANKFORD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 N MICHIGAN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-1035
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 HIGHLANDER POINT DR STE 300
Practice Address - Street 2:
Practice Address - City:FLOYDS KNOBS
Practice Address - State:IN
Practice Address - Zip Code:47119-9465
Practice Address - Country:US
Practice Address - Phone:812-923-2273
Practice Address - Fax:812-923-1400
Is Sole Proprietor?:No
Enumeration Date:2019-04-29
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN02006643A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program