Healthcare Provider Details

I. General information

NPI: 1679596712
Provider Name (Legal Business Name): JOHN A DESANTO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 12/26/2024
Certification Date: 12/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13050 PARKSIDE DR STE 101
FISHERS IN
46038-8247
US

IV. Provider business mailing address

6626 E 75TH ST SUITE 500
INDIANAPOLIS IN
46250-2890
US

V. Phone/Fax

Practice location:
  • Phone: 317-621-2290
  • Fax:
Mailing address:
  • Phone: 317-355-2184
  • Fax: 317-355-2185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01038336A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: