Provider Demographics
NPI:1184185498
Name:JABATI, SALLU (MD)
Entity type:Individual
Prefix:
First Name:SALLU
Middle Name:
Last Name:JABATI
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 1:2080 44TH ST SE STE 120
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-5299
Mailing Address - Country:US
Mailing Address - Phone:616-500-0977
Mailing Address - Fax:
Practice Address - Street 1:2080 44TH ST SE STE 120
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-5299
Practice Address - Country:US
Practice Address - Phone:616-500-0977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-28
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301510992207L00000X, 207LP2900X
IL036165223207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036.165223OtherPERMANENT MEDICAL LICENSE