Provider Demographics
NPI:1457730830
Name:STUDTMAN, PATRICK LEE (DO)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:LEE
Last Name:STUDTMAN
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 1:615 N MICHIGAN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-1087
Mailing Address - Country:US
Mailing Address - Phone:574-647-7459
Mailing Address - Fax:574-647-3658
Practice Address - Street 1:615 N. MICHIGAN STREET
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1033
Practice Address - Country:US
Practice Address - Phone:574-647-7459
Practice Address - Fax:574-647-3658
Is Sole Proprietor?:No
Enumeration Date:2015-05-19
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02005200A207P00000X
MI5101021681390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN941030015OtherMEDICARE PTAN
IN300008298Medicaid