Provider Demographics
NPI:1679596712
Name:DESANTO, JOHN A
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:DESANTO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:317-355-2184
Mailing Address - Fax:317-355-2185
Practice Address - Street 1:13050 PARKSIDE DR STE 101
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46038-8247
Practice Address - Country:US
Practice Address - Phone:317-621-2290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01038336A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100354250Medicaid
INE44301Medicare UPIN
IN213810CMedicare PIN
INM400043099Medicare PIN