Provider Demographics
NPI:1174925317
Name:DE SANTIS, MARC RICHARD (LAC)
Entity type:Individual
Prefix:MR
First Name:MARC
Middle Name:RICHARD
Last Name:DE SANTIS
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 OAK SPRING RD
Mailing Address - Street 2:
Mailing Address - City:WEST NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10994-1209
Mailing Address - Country:US
Mailing Address - Phone:917-514-6815
Mailing Address - Fax:
Practice Address - Street 1:6 OAK SPRING RD
Practice Address - Street 2:
Practice Address - City:WEST NYACK
Practice Address - State:NY
Practice Address - Zip Code:10994-1209
Practice Address - Country:US
Practice Address - Phone:917-514-6815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-18
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005401171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist