Provider Demographics
NPI:1689618068
Name:POWELL, JOHN F (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:F
Last Name:POWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 CEDAR ST STE 405
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2059
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:234 CHAPIN ST STE I
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-2571
Practice Address - Country:US
Practice Address - Phone:574-335-8250
Practice Address - Fax:574-335-0788
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01029534A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1102413754OtherANTHEM
IN100223260Medicaid
IN000001314275OtherBCBS
INC25582Medicare UPIN
IN080181622Medicare PIN