Individual
MELVIN SUSANTO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
12404 LIMA CROSSING DR, FORT WAYNE, IN 46818-0202
(260) 458-3740
(260) 458-3741
Mailing address
6920 POINTE INVERNESS WAY STE 200, FORT WAYNE, IN 46804-7934
(260) 458-3740
(260) 458-3741
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
01091229A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
300052108
—
IN
Enumeration date
06/15/2021
Last updated
09/09/2024
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