Provider Demographics
NPI:1700033727
Name:SANTHANAM ETHIRAJ, SAMPATH KUMAR (MBBS)
Entity Type:Individual
Prefix:DR
First Name:SAMPATH
Middle Name:KUMAR
Last Name:SANTHANAM ETHIRAJ
Suffix:
Gender:M
Credentials:MBBS
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Other - First Name:
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Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11109 PARKVIEW PLAZA DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1701
Practice Address - Country:US
Practice Address - Phone:260-672-6620
Practice Address - Fax:260-672-6639
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-20
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301092338207R00000X
IN01072529A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine