Healthcare Provider Details

I. General information

NPI: 1093714818
Provider Name (Legal Business Name): JACK S. BARTOSZEK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 09/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 FULMER RD
MISHAWAKA IN
46544-6911
US

IV. Provider business mailing address

4455 EDISON LAKES PKWY UNITY MEDICAL SURGICAL HOSPITAL
MISHAWAKA IN
46545-1442
US

V. Phone/Fax

Practice location:
  • Phone: 574-252-3085
  • Fax: 574-252-5906
Mailing address:
  • Phone: 574-252-3085
  • Fax: 574-252-5906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number02001105
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: