Provider Demographics
NPI:1255380903
Name:CHADWELL, JON BLAKE (MD)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:BLAKE
Last Name:CHADWELL
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 1:6301 UNIVERSITY COMMONS
Mailing Address - Street 2:SUITE 360
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1571
Mailing Address - Country:US
Mailing Address - Phone:574-232-4800
Mailing Address - Fax:574-280-4810
Practice Address - Street 1:6301 UNIVERSITY COMMONS
Practice Address - Street 2:SUITE 360
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1571
Practice Address - Country:US
Practice Address - Phone:574-232-4800
Practice Address - Fax:574-280-4810
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01061815A207YX0905X
CO43615207YX0905X
OH35 085143207YX0905X
KY39547207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01061815AOtherINDIANA LICENSE
IN000000485851OtherANTHEM PIN
IN200523340AMedicaid
INBC9150878OtherDEA
IN000000485851OtherANTHEM PIN
IN01061815AOtherINDIANA LICENSE
IN739280LMedicare PIN