Provider Demographics
NPI:1467542498
Name:DESANTIS, MARSHALL MATTHEW (MD)
Entity Type:Individual
Prefix:DR
First Name:MARSHALL
Middle Name:MATTHEW
Last Name:DESANTIS
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 1:14100 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
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0053627208G00000X
FLME53627208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL07035OtherBCBS FLORIDA
083596OtherAVMED
FL048693100Medicaid
083596OtherAVMED
FL07035OtherBCBS FLORIDA
FL048693100Medicaid