Healthcare Provider Details

I. General information

NPI: 1790790657
Provider Name (Legal Business Name): FAUSTO ODON MAGNO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2006
Last Update Date: 12/21/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8315 VIRGINIA ST STE M
MERRILLVILLE IN
46410-9201
US

IV. Provider business mailing address

8315 VIRGINIA ST STE M
MERRILLVILLE IN
46410-9201
US

V. Phone/Fax

Practice location:
  • Phone: 219-736-1500
  • Fax: 219-736-1551
Mailing address:
  • Phone: 219-736-1500
  • Fax: 219-736-1551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01054491A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: