Provider Demographics
NPI:1710962915
Name:ZABUKOVIC, BRANDON WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:WILLIAM
Last Name:ZABUKOVIC
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 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:574-237-6069
Practice Address - Street 1:621 MEMORIAL DR STE 402
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1074
Practice Address - Country:US
Practice Address - Phone:574-400-4550
Practice Address - Fax:574-400-4551
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2019-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01058060A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000488743OtherBCBS MAIN STREET
IN200455430Medicaid
P00406499OtherRR MEDICARE
IN000000483222OtherBCBS BMG CENTRAL NEIGHBORHOOD CTR
IN000000789419OtherBCBS BMG CENTENNIAL NEIGHBORHOOD CTR
IN000000488793OtherBCBS BMG E BLAIR WARNER
IN941030IIIMedicare PIN
IN000000789419OtherBCBS BMG CENTENNIAL NEIGHBORHOOD CTR
IN236040D3Medicare PIN
IN000000483222OtherBCBS BMG CENTRAL NEIGHBORHOOD CTR
IN000000488743OtherBCBS MAIN STREET
IN178420YMedicare PIN