MEDICARE: MICHAEL E PORVAZNIK MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	01060166A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1689679482
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL E PORVAZNIK MD

Provider Business Mailing Address
First Line	:	3211 W REDDY WAY
Second Line	:
City	:	BLOOMINGTON
State	:	IN
Zip	:	47403-4066
Country	:	US
Telephone Number	:	812-825-0777
Fax Number	:

Provider Business Practice Location Address
First Line	:	3211 W REDDY WAY
Second Line	:
City	:	BLOOMINGTON
State	:	IN
Zip	:	47403-4066
Country	:	US
Telephone Number	:	812-825-0777
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/17/2005
Last Update Date	:	03/27/2025

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