Provider Demographics
NPI:1548373822
Name:SANTOSO, IVAN (DO)
Entity type:Individual
Prefix:DR
First Name:IVAN
Middle Name:
Last Name:SANTOSO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 MASSILLON RD STE 102
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44312-5982
Mailing Address - Country:US
Mailing Address - Phone:330-896-3036
Mailing Address - Fax:330-896-0464
Practice Address - Street 1:3333 MASSILLON RD STE 102
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44312-5982
Practice Address - Country:US
Practice Address - Phone:330-896-3036
Practice Address - Fax:330-896-0464
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-006940207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2137904Medicaid
OH9344931Medicare ID - Type Unspecified
OH2137904Medicaid