Provider Demographics
NPI:1083836449
Name:FATA, JOSEPH JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:JOHN
Last Name:FATA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10293 N MERIDIAN ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46290-1123
Mailing Address - Country:US
Mailing Address - Phone:317-575-9152
Mailing Address - Fax:317-575-9281
Practice Address - Street 1:10293 N MERIDIAN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46290-1123
Practice Address - Country:US
Practice Address - Phone:317-575-9152
Practice Address - Fax:317-575-9281
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010405632086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN198580Medicare ID - Type Unspecified
INA60367Medicare UPIN