Provider Demographics
NPI:1437383171
Name:MARSHALL M. DESANTIS, M.D.,PA
Entity Type:Organization
Organization Name:MARSHALL M. DESANTIS, M.D.,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EMPLOYER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARSHALL
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:DESANTIS,
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-869-7497
Mailing Address - Street 1:14100 FIVAY RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:HUDSON
Mailing Address - State:FL
Mailing Address - Zip Code:34667-7180
Mailing Address - Country:US
Mailing Address - Phone:727-869-7497
Mailing Address - Fax:727-869-7156
Practice Address - Street 1:14100 FIVAY RD
Practice Address - Street 2:SUITE 300
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667-7180
Practice Address - Country:US
Practice Address - Phone:727-869-7497
Practice Address - Fax:727-869-7156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-10
Last Update Date:2009-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME53627174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL07035OtherBLUE CROSS BLUE SHIELD
FL593277301OtherUNIVERSAL
FL048693100Medicaid
FL593277301OtherTRICARE
FL593277301OtherHUMANA
FL4049845OtherAETNA
FL05632OtherWELLCARE
FL083596OtherAV MED
FL1467542498OtherUNITED
FLPRO0035OtherQUALITY
FL593277301OtherCIGNA
FL593277301OtherCIGNA
FL048693100Medicaid