Provider Demographics
NPI:1447560834
Name:RICHARD A. DE SANTIS, PH.D., M.D., P.C.
Entity Type:Organization
Organization Name:RICHARD A. DE SANTIS, PH.D., M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:DE SANTIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-838-5208
Mailing Address - Street 1:715 S SHAMROCK RD
Mailing Address - Street 2:
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21014-4457
Mailing Address - Country:US
Mailing Address - Phone:410-838-5208
Mailing Address - Fax:410-838-6129
Practice Address - Street 1:715 S SHAMROCK RD
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-4457
Practice Address - Country:US
Practice Address - Phone:410-838-5208
Practice Address - Fax:410-838-6129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-19
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD40938261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD698491600Medicaid
MD698491600Medicaid