Provider Demographics
NPI:1093837411
Name:SAMALIO, JUSTO SANTOS III (DC)
Entity Type:Individual
Prefix:DR
First Name:JUSTO
Middle Name:SANTOS
Last Name:SAMALIO
Suffix:III
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 COMMERCE SQ
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-3282
Mailing Address - Country:US
Mailing Address - Phone:210-872-2273
Mailing Address - Fax:219-872-5147
Practice Address - Street 1:240 COMMERCE SQ
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-3282
Practice Address - Country:US
Practice Address - Phone:210-872-2273
Practice Address - Fax:219-872-5147
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001758A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN150540Medicare ID - Type Unspecified
INU80290Medicare UPIN