Healthcare Provider Details

I. General information

NPI: 1952500415
Provider Name (Legal Business Name): JACK STADDON M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2007
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 N MICHIGAN ST FL 4
SOUTH BEND IN
46601-1033
US

IV. Provider business mailing address

3245 HEALTH DR STE 100
GRANGER IN
46530-1380
US

V. Phone/Fax

Practice location:
  • Phone: 574-647-6892
  • Fax: 574-647-6895
Mailing address:
  • Phone: 574-647-3725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number01099630A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number04-45815
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: