Provider Demographics
NPI:1437304813
Name:SANTOSO, LIMJADI (MD)
Entity Type:Individual
Prefix:
First Name:LIMJADI
Middle Name:
Last Name:SANTOSO
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 1:1130 SAINT ANN DR
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16509-2945
Mailing Address - Country:US
Mailing Address - Phone:814-864-1209
Mailing Address - Fax:814-864-1209
Practice Address - Street 1:1130 SAINT ANN DR
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16509-2945
Practice Address - Country:US
Practice Address - Phone:814-864-1209
Practice Address - Fax:814-864-1209
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-26
Last Update Date:2008-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD 032452L207Q00000X
PAMD032452L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAC29765Medicare UPIN