Provider Demographics
NPI:1386640878
Name:DISANTO, KERRY (MD)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:DISANTO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1860 PAYSPHERE CIR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-0001
Mailing Address - Country:US
Mailing Address - Phone:630-986-8770
Mailing Address - Fax:630-986-8776
Practice Address - Street 1:908 N ELM ST
Practice Address - Street 2:STE 110
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-3635
Practice Address - Country:US
Practice Address - Phone:630-986-8770
Practice Address - Fax:630-986-8776
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036-0888862084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-088886Medicaid