Provider Demographics
NPI:1427047950
Name:LAMBERT, DESTRY W (MD)
Entity type:Individual
Prefix:MR
First Name:DESTRY
Middle Name:W
Last Name:LAMBERT
Suffix:
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:PO BOX 358
Mailing Address - Street 2:
Mailing Address - City:TIPTON
Mailing Address - State:IN
Mailing Address - Zip Code:46072-0358
Mailing Address - Country:US
Mailing Address - Phone:765-675-8119
Mailing Address - Fax:765-675-8257
Practice Address - Street 1:403 FAIRGROUNDS RD
Practice Address - Street 2:
Practice Address - City:TIPTON
Practice Address - State:IN
Practice Address - Zip Code:46072-9596
Practice Address - Country:US
Practice Address - Phone:765-675-7601
Practice Address - Fax:765-675-8052
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01024399208D00000X
IN01024399A208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100233710AMedicaid
D70777Medicare UPIN
IN810490AMedicare PIN