Provider Demographics
NPI:1376578724
Name:DESANTIS, KIMBERLY M (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:M
Last Name:DESANTIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ELLEN
Other - Last Name:METZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:415 HOOPER RD
Mailing Address - Street 2:
Mailing Address - City:ENDWELL
Mailing Address - State:NY
Mailing Address - Zip Code:13760-3646
Mailing Address - Country:US
Mailing Address - Phone:607-754-3863
Mailing Address - Fax:607-754-5697
Practice Address - Street 1:415 HOOPER RD
Practice Address - Street 2:ENDWELL FAMILY PHYSICIANS LLP
Practice Address - City:ENDWELL
Practice Address - State:NY
Practice Address - Zip Code:13760-3646
Practice Address - Country:US
Practice Address - Phone:607-754-3863
Practice Address - Fax:607-754-5697
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY211449207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
10074276OtherCDPHP
7455028OtherAETNA HMO
NY01943728Medicaid
5997006OtherGHI
699965OtherMVP
71561388OtherCHAMPUS
153925OtherEMPIRE BS
153925OtherEXCELLUS
699965OtherMVP SELECT
153925OtherBS CNY
153925OtherHMO BLUE
7455028OtherAETNA
153925OtherBLUEPOINT
76410OtherGHI HMO
699965OtherMVP
G93463Medicare UPIN