Provider Demographics
NPI:1154339935
Name:HANNON, LAURA A (MD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:A
Last Name:HANNON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2022 KELLE DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-8708
Mailing Address - Country:US
Mailing Address - Phone:219-326-2312
Mailing Address - Fax:219-326-2584
Practice Address - Street 1:8988 E US HIGHWAY 20
Practice Address - Street 2:
Practice Address - City:NEW CARLISLE
Practice Address - State:IN
Practice Address - Zip Code:46552-9038
Practice Address - Country:US
Practice Address - Phone:574-654-7779
Practice Address - Fax:574-654-7780
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01061101A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN00000378303OtherANTHEM, BCBS
IN200529120AMedicaid
IN200529120AMedicaid
IN151020 V VMedicare PIN