Provider Demographics
NPI:1871460055
Name:JULIJANTO, HAGGAN
Entity type:Individual
Prefix:
First Name:HAGGAN
Middle Name:
Last Name:JULIJANTO
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14053 FOUR SEASONS WAY
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46074-8588
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2004 W SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46901-4112
Practice Address - Country:US
Practice Address - Phone:574-780-0102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-21
Last Update Date:2025-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10005054A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant