Basic Information
| Provider Information | |||||||||
| NPI: | 1366623381 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OZIMEK | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1801 N SENATE BLVD | ||||||||
| Address2: | SUITE 755 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179231787 | ||||||||
| FaxNumber: | 3179626259 | ||||||||
| Practice Location | |||||||||
| Address1: | 1801 N. SENATE BLVD. | ||||||||
| Address2: | SUITE 755 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462021260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179231787 | ||||||||
| FaxNumber: | 3179626259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2007 | ||||||||
| LastUpdateDate: | 06/24/2019 | ||||||||
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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 | 363AM0700X | 50.002707 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 10001060A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | OZPA29961 | 01 | OH | MEDICARE PTAN | OTHER | 300026718 | 05 | IN | MEDICAID |