Provider Demographics
NPI:1366442584
Name:DE SANTIS, STEPHEN A (MD)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:A
Last Name:DE SANTIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1280 E. ALMOND AVENUE
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93637-5606
Mailing Address - Country:US
Mailing Address - Phone:559-673-9021
Mailing Address - Fax:559-673-0479
Practice Address - Street 1:1280 E. ALMOND AVENUE
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93637-5606
Practice Address - Country:US
Practice Address - Phone:559-673-9021
Practice Address - Fax:559-673-0479
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG40996A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG40996AOtherPIN
CAWG40996AOtherPIN