Provider Demographics
NPI:1275791196
Name:SANTHOSAM, JABAKAR (PT)
Entity Type:Individual
Prefix:MR
First Name:JABAKAR
Middle Name:
Last Name:SANTHOSAM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7064 CHESTERTON CIR
Mailing Address - Street 2:BLDG # 5
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-8304
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:501 17TH STREET
Practice Address - Street 2:BEECH GROVE
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46207
Practice Address - Country:US
Practice Address - Phone:317-786-2670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-28
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05009173A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist