MEDICARE: MELVIN SUSANTO MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	01091229A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558939629
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELVIN SUSANTO MD

Provider Business Mailing Address
First Line	:	6920 POINTE INVERNESS WAY STE 200
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-7934
Country	:	US
Telephone Number	:	260-458-3740
Fax Number	:	260-458-3741

Provider Business Practice Location Address
First Line	:	12404 LIMA CROSSING DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46818-0202
Country	:	US
Telephone Number	:	260-458-3740
Fax Number	:	260-458-3741

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2021
Last Update Date	:	09/09/2024

Similar Medicare Providers

1124802475 — LAUREN GRACE ARIAS FNP-C
Practice Location Address:

12404 LIMA CROSSING DR
FORT WAYNE, IN
46818-0202

Practice Phone: 260-478-4201
Practice Fax: 260-458-3248

1750392676 — DUANE P JOHNSON DO
Practice Location Address:

12404 LIMA CROSSING DR
FORT WAYNE, IN
46818-0202

Practice Phone: 260-478-4201
Practice Fax: 260-458-3248

1598444846 — EMILY METZINGER FNP
Practice Location Address:

12404 LIMA CROSSING DR
FORT WAYNE, IN
46818-0202

Practice Phone: 260-458-3740
Practice Fax:

1720166853 — SUPERIOR VAN & MOBILITY
Practice Location Address:

2218 CONTRACTORS WAY
FORT WAYNE, IN
46818-1721

Practice Phone: 260-497-8267
Practice Fax: 260-490-4484

1225989924 — THREE RIVERS THERAPY LLC
Practice Location Address:

10434 CHERRY CREEK RD
FORT WAYNE, IN
46818-8865

Practice Phone: 260-403-4252
Practice Fax:

1184622367 — TODD ROBERT PAGE MD
Practice Location Address:

5501 US HIGHWAY 30 W
FORT WAYNE, IN
46818-8998

Practice Phone: 260-270-6181
Practice Fax: 260-469-1022

Directions to “ MELVIN SUSANTO MD” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

Copyright © 2007-2026 (Powered by Swiss Vault Engine), all rights reserved. HIPAA liability, trademark, document use and software licensing rules apply. All registered trademarks, used in the content, are the property of their owners. Your interactions with this site are in accordance with our Terms of Use and Privacy Policy.