Provider Demographics
NPI:1043219397
Name:DISANDRO, DEBRA A (MD)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:A
Last Name:DISANDRO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3550 MAIN ST STE 302
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01107-1088
Mailing Address - Country:US
Mailing Address - Phone:413-781-8290
Mailing Address - Fax:413-732-7628
Practice Address - Street 1:3550 MAIN ST STE 302
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1088
Practice Address - Country:US
Practice Address - Phone:413-781-8290
Practice Address - Fax:413-737-8540
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA52978207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA037323836OtherTRICARE
MA11833OtherHEALTH NEW ENGLAND
MA484978OtherCONNECTICARE
MADIJ06185OtherBLUE SHIELD OF MASS
MA717957OtherTUFTS
MA130705OtherPILGRIM
MA160039235OtherRR MEDICARE
MA782507OtherUS HEALTHCARE
MA0010789OtherNEIGHBORHOOD HEALTH
MA07-04622OtherUNITED HEALTHCARE
MA3017699Medicaid
MA000006311OtherBMC HEALTHNET
MA3017699Medicaid
MAJ06185Medicare PIN