Provider records sourced from NPPES (CMS National Plan & Provider Enumeration System). Data current as of August 10, 2026.
NPIDirectory

Melvin Susanto, MD

Individual provider Family Medicine Physician · NPI 1558939629

Melvin Susanto, MD is a Family Practice in Fort Wayne, Indiana. Qualified in 2021, 5 years ago. Practices with Lutheran Medical Group LLC, a 250-clinician group and accepts Medicare assignment. Licensed in Indiana.

Years since qualifying
5
Licensed in
IN
In the registry since
2021
What do these letters mean?
MD — Doctor of Medicine
A physician who completed allopathic medical school.

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Practice location Address checks out

12404 Lima Crossing Dr
Fort Wayne, IN 46818-0202
Phone: (260) 458-3740
Fax: (260) 458-3741
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Pin is approximate — placed at the ZIP-code centre, not the exact door.

Specialties & licences

Family Medicine Physician (primary) Taxonomy 207Q00000X · Licence 01091229A (IN)

Record details

NPI number1558939629
Entity typeIndividual (Type 1)
GenderMale
Credentials MD
Sole proprietorNo
NPI enumeratedJune 15, 2021
Last updated in NPPESSeptember 9, 2024
Certification dateSeptember 9, 2024
Mailing address6920 Pointe Inverness Way Ste 200, Fort Wayne, IN 46804-7934

Medicare enrollment

From the CMS Doctors & Clinicians file — this clinician is enrolled in Medicare.

Medicare specialtyFAMILY PRACTICE
Medical schoolOTHER
Graduated 2021 (5 years in practice)
Group practice Lutheran Medical Group Llc — 250 clinicians
Accepts Medicare assignment Yes — accepts the Medicare-approved amount

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