Provider Demographics
NPI:1528176021
Name:SUTANTO, JOHN S (DC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:S
Last Name:SUTANTO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6S051 STEEPLE RUN DR
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-3732
Mailing Address - Country:US
Mailing Address - Phone:630-376-0625
Mailing Address - Fax:
Practice Address - Street 1:6S051 STEEPLE RUN DR
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-3732
Practice Address - Country:US
Practice Address - Phone:630-376-0625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition