Basic Information
Provider Information | |||||||||
NPI: | 1205044195 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WEEKS | ||||||||
FirstName: | LARA | ||||||||
MiddleName: | KATHRYN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BUCHE | ||||||||
OtherFirstName: | LARA | ||||||||
OtherMiddleName: | KATHRYN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 1200 W WHITE RIVER BLVD | ||||||||
Address2: |   | ||||||||
City: | MUNCIE | ||||||||
State: | IN | ||||||||
PostalCode: | 473034988 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8776685621 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2600 GREENBUSH ST | ||||||||
Address2: |   | ||||||||
City: | LAFAYETTE | ||||||||
State: | IN | ||||||||
PostalCode: | 479042477 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7654488000 | ||||||||
FaxNumber: | 7654487644 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/21/2007 | ||||||||
LastUpdateDate: | 03/01/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/01/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 01066853A | IN | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208000000X | 01066853A | IN | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 000000618966 | 01 | IN | ANTHEM | OTHER | 000001024783 | 01 | IN | INTERNAL MED ANTHEM PIN UNDER TIN 35-2030653 | OTHER | 200954280 | 05 | IN |   | MEDICAID | 000001037742 | 01 | IN | PEDIATRIC ANTHEM PIN UNDER TIN 35-2030653 | OTHER |