Provider Demographics
NPI:1124317102
Name:ESTABROOK, NEIL CRAINE III (MD)
Entity type:Individual
Prefix:DR
First Name:NEIL
Middle Name:CRAINE
Last Name:ESTABROOK
Suffix:III
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 1:1200 W WHITE RIVER BLVD
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-4988
Mailing Address - Country:US
Mailing Address - Phone:877-668-5621
Mailing Address - Fax:
Practice Address - Street 1:420 N 26TH ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2848
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:765-448-7623
Is Sole Proprietor?:No
Enumeration Date:2011-03-30
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN01076841A2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000001017968OtherANTHEM PROVIDER NUMBER
IN201101670Medicaid
IN815500152Medicare PIN