Provider Demographics
NPI:1528173341
Name:LAFOLLETTE, CHRISTOPHER P (MD)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:P
Last Name:LAFOLLETTE
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 1:995 S CLARIZZ BLVD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-5588
Mailing Address - Country:US
Mailing Address - Phone:812-353-3060
Mailing Address - Fax:812-353-3070
Practice Address - Street 1:995 S CLARIZZ BLVD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401
Practice Address - Country:US
Practice Address - Phone:812-353-3060
Practice Address - Fax:812-353-3070
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01062447A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200830830Medicaid
IN200830830Medicaid
INM400022182Medicare PIN