Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 02005480A | IN |
NPI | 1003336561 |
---|---|
Provider Name | Ian Reed |
First Address | Lafayette, IN 47903-4699 |
Second Address | Lafayette, IN 47904-3028 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/06/2017 |
Last Update Date | 29/07/2020 |