Healthcare Provider Details

I. General information

NPI: 1275995219
Provider Name (Legal Business Name): MATTHEW PAZDERKA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2016
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

765 S MICHIGAN ST
SOUTH BEND IN
46601-3101
US

IV. Provider business mailing address

8003 CASTLEWAY DR
INDIANAPOLIS IN
46250-1946
US

V. Phone/Fax

Practice location:
  • Phone: 574-235-7990
  • Fax: 574-847-7201
Mailing address:
  • Phone: 317-576-1335
  • Fax: 317-343-6562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01099563A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301117376
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: