Provider Demographics
NPI:1962508812
Name:BOBZIEN, MATTHEW THOMAS IV (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:THOMAS
Last Name:BOBZIEN
Suffix:IV
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 1:2605 N LEBANON ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IN
Mailing Address - Zip Code:46052-1476
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 N LEBANON ST
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:IN
Practice Address - Zip Code:46147-9372
Practice Address - Country:US
Practice Address - Phone:765-676-5754
Practice Address - Fax:765-676-9853
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01058567A208M00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200487780Medicaid
INI17564Medicare UPIN
IN1962508812OtherNPI
IN200487780Medicaid
IN1083750293OtherGROUP NPI