Basic Information
| Provider Information | |||||||||
| NPI: | 1003066325 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARKIEWICZ | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1007 LINCOLNWAY | ||||||||
| Address2: | |||||||||
| City: | LA PORTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463503201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193262305 | ||||||||
| FaxNumber: | 2193262605 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 UNIVERSITY BLVD | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462025149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172789729 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2008 | ||||||||
| LastUpdateDate: | 10/17/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 01072267A | IN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | P01293671 | 01 | IN | RAILROAD MEDICARE | OTHER | 201172270 | 05 | IN | MEDICAID |