Provider Demographics
NPI:1528034071
Name:DESANTIS, DONALD (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:
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 1:552A LANCASTER AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:PA
Mailing Address - Zip Code:19312-1635
Mailing Address - Country:US
Mailing Address - Phone:610-644-7100
Mailing Address - Fax:610-644-7111
Practice Address - Street 1:552A LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:PA
Practice Address - Zip Code:19312-1635
Practice Address - Country:US
Practice Address - Phone:610-644-7100
Practice Address - Fax:610-644-7111
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200200107208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1700922OtherUNITED HEALTHCARE NUMBER
NC5435826OtherCIGNA NUMBER
NC89137P1Medicaid
NC4087699OtherAETNA NUMBER
NCD5599OtherMEDCOST NUMBER
NC2130600OtherMAMSI NUMBER
NC137P1OtherBCBS NUMBER
NC804764OtherPARTNERS MEDICARE CHOICE
NC2130600OtherMAMSI NUMBER
NC2032416Medicare PIN