Provider Demographics
NPI:1003985417
Name:DE SANCTIS, CARLOS MANUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:MANUEL
Last Name:DE SANCTIS
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:PO BOX 1337
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87305-1337
Mailing Address - Country:US
Mailing Address - Phone:505-722-1000
Mailing Address - Fax:505-722-1268
Practice Address - Street 1:516 E. NIZHONI BLVD.
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301
Practice Address - Country:US
Practice Address - Phone:505-722-1000
Practice Address - Fax:505-722-1268
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12531208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics