Provider Demographics
NPI:1023198512
Name:DISANTO, CHARLES D (PT,COMT,CHT)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:D
Last Name:DISANTO
Suffix:
Gender:M
Credentials:PT,COMT,CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4517 STATE ROUTE 269 S
Mailing Address - Street 2:
Mailing Address - City:CASTALIA
Mailing Address - State:OH
Mailing Address - Zip Code:44824-9356
Mailing Address - Country:US
Mailing Address - Phone:419-684-8091
Mailing Address - Fax:
Practice Address - Street 1:1 E WILLARD AVE
Practice Address - Street 2:SUITE B
Practice Address - City:NORWALK
Practice Address - State:OH
Practice Address - Zip Code:44857-1155
Practice Address - Country:US
Practice Address - Phone:419-660-0876
Practice Address - Fax:419-660-9104
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT07840225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2471507Medicaid
OH4122791Medicare PIN