Basic Information
| Provider Information | |||||||||
| NPI: | 1700220720 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOYLE | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | BALANDRAN | ||||||||
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| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | BALANDRAN | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3500 GASTON AVE | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752462017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2148202361 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11700 N MERIDIAN ST | ||||||||
| Address2: | |||||||||
| City: | CARMEL | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176882000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2013 | ||||||||
| LastUpdateDate: | 04/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | R7958 | TX | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 390200000X | BP10047403 | TX | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207V00000X | 01080958B | IN | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 1700220720 | 05 | IN | MEDICAID |