Provider Demographics
NPI:1790767465
Name:MISCH, JON D (DO)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:D
Last Name:MISCH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13963 MORSE STREET
Mailing Address - Street 2:
Mailing Address - City:CEDAR LAKE
Mailing Address - State:IN
Mailing Address - Zip Code:46303-9639
Mailing Address - Country:US
Mailing Address - Phone:219-374-5555
Mailing Address - Fax:219-374-6669
Practice Address - Street 1:13963 MORSE STREET
Practice Address - Street 2:
Practice Address - City:CEDAR LAKE
Practice Address - State:IN
Practice Address - Zip Code:46303-9639
Practice Address - Country:US
Practice Address - Phone:219-374-5555
Practice Address - Fax:219-374-6669
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02000900A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000087109OtherANTHEM PROVIDER #
IN90000256OtherBLUE CROSS/BLUE SHIELD IL
INE26972Medicare UPIN
IN000000087109OtherANTHEM PROVIDER #