Provider Demographics
NPI:1336330703
Name:DE SANTO, RONALD J (CPED)
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:J
Last Name:DE SANTO
Suffix:
Gender:M
Credentials:CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1635 N HOWE ST
Mailing Address - Street 2:STE H
Mailing Address - City:SOUTHPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28461
Mailing Address - Country:US
Mailing Address - Phone:910-454-4545
Mailing Address - Fax:910-454-0122
Practice Address - Street 1:1635 N HOWE ST
Practice Address - Street 2:STE H
Practice Address - City:SOUTHPORT
Practice Address - State:NC
Practice Address - Zip Code:28461
Practice Address - Country:US
Practice Address - Phone:910-454-4545
Practice Address - Fax:910-454-0122
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCPED1438174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7795071Medicaid