Provider Demographics
NPI:1467566380
Name:DESANTIS, CARLA (MD)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:
Last Name:DESANTIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 HAZARD AVE
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082
Mailing Address - Country:US
Mailing Address - Phone:860-763-4001
Mailing Address - Fax:860-749-5592
Practice Address - Street 1:170 HAZARD AVE
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082
Practice Address - Country:US
Practice Address - Phone:860-763-4001
Practice Address - Fax:860-749-5592
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT036524207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001365247Medicaid
160001725Medicare ID - Type Unspecified
G63370Medicare UPIN