Provider Demographics
NPI:1437193513
Name:DISANTIS, DENNIS E (MD)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:E
Last Name:DISANTIS
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 1:2675 N DECATUR RD
Mailing Address - Street 2:SUITE 506
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-6131
Mailing Address - Country:US
Mailing Address - Phone:404-299-1679
Mailing Address - Fax:404-508-7694
Practice Address - Street 1:2675 N DECATUR RD
Practice Address - Street 2:SUITE 506
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-6131
Practice Address - Country:US
Practice Address - Phone:404-299-1679
Practice Address - Fax:404-508-7694
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA018138207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00110162AMedicaid
GA582322161OtherFEDERAL TAX ID
GA00110162AMedicaid
GA10BBBZG03Medicare PIN