Provider Demographics
NPI:1487644399
Name:DESANCTIS, ROMAN WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:ROMAN
Middle Name:WILLIAM
Last Name:DESANCTIS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 9142
Mailing Address - Street 2:MASS GENERAL PHYSICIAN ORGANIZATION
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-726-2889
Mailing Address - Fax:617-643-1615
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:CARDIAC UNIT ASSOCIATES
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:617-726-2889
Practice Address - Fax:617-643-1615
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2012-07-23
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Provider Licenses
StateLicense IDTaxonomies
MA26198207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA715637OtherTUFTS HEALTH PLAN
MAM04093OtherBCBS MA
MA0121568Medicaid
MAM04093Medicare ID - Type Unspecified
MA0121568Medicaid