Provider Demographics
NPI:1912992629
Name:SOBOLEWSKI, JOHN A (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:SOBOLEWSKI
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:PO BOX 1430
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-9230
Mailing Address - Country:US
Mailing Address - Phone:219-763-8112
Mailing Address - Fax:219-764-3251
Practice Address - Street 1:2490 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LAKE STATION
Practice Address - State:IN
Practice Address - Zip Code:46405-2122
Practice Address - Country:US
Practice Address - Phone:219-763-8112
Practice Address - Fax:219-764-3251
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036528A208D00000X, 2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200106540Medicaid
E30891Medicare UPIN
IN170680ZMedicare ID - Type Unspecified