Provider Demographics
NPI:1053317545
Name:DESANTIS, NICHOLAS NELSON (DPM)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:NELSON
Last Name:DESANTIS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2306 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-1643
Mailing Address - Country:US
Mailing Address - Phone:619-239-3286
Mailing Address - Fax:619-239-0172
Practice Address - Street 1:2306 6TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-1643
Practice Address - Country:US
Practice Address - Phone:619-239-3286
Practice Address - Fax:619-239-0172
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-21
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2474213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E24740OtherBLUE CROSS
CA000E24741Medicaid
CA000E24741Medicaid
CAE2474BMedicare PIN
CA000E24740OtherBLUE CROSS