Provider Demographics
NPI:1932185279
Name:LEBAMOFF, JAMES (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:LEBAMOFF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 UNION CHAPEL RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-9357
Mailing Address - Country:US
Mailing Address - Phone:260-428-4440
Mailing Address - Fax:260-482-4442
Practice Address - Street 1:10 JOHN KISSINGER DR
Practice Address - Street 2:
Practice Address - City:WABASH
Practice Address - State:IN
Practice Address - Zip Code:46992-1648
Practice Address - Country:US
Practice Address - Phone:260-563-3131
Practice Address - Fax:260-482-4442
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2024-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036569207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000191935OtherBC/BS
IN200036420AMedicaid
IN930106017OtherRAILROAD MEDICARE
IN200036420AMedicaid
IN930106017OtherRAILROAD MEDICARE