Provider Demographics
NPI:1689679482
Name:PORVAZNIK, MICHAEL E (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:E
Last Name:PORVAZNIK
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3211 W REDDY WAY
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-4066
Mailing Address - Country:US
Mailing Address - Phone:812-825-0777
Mailing Address - Fax:
Practice Address - Street 1:3211 W REDDY WAY
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-4066
Practice Address - Country:US
Practice Address - Phone:812-825-0777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01060166A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200510710Medicaid
INM400022199Medicare PIN
IN200510710Medicaid
IN549250LMedicare ID - Type Unspecified
INM400022199Medicare PIN