Provider Demographics
NPI:1235104431
Name:JABATI, SALLU M (MD)
Entity type:Individual
Prefix:DR
First Name:SALLU
Middle Name:M
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 1:3908 SHADOW LOCH DR
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-7455
Mailing Address - Country:US
Mailing Address - Phone:678-559-4526
Mailing Address - Fax:
Practice Address - Street 1:3130 N ARIZONA AVE STE 112
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85225-7163
Practice Address - Country:US
Practice Address - Phone:480-292-8579
Practice Address - Fax:480-306-6029
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-21
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ36200208VP0014X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ299505Medicaid