Provider Demographics
NPI:1578582474
Name:DISANTI, STEVEN J (DO)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:J
Last Name:DISANTI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6550 E RIVERSIDE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-4424
Mailing Address - Country:US
Mailing Address - Phone:815-633-4100
Mailing Address - Fax:815-633-5141
Practice Address - Street 1:109 SOUTH GENOA STREET
Practice Address - Street 2:GENOA MEDICAL CLINIC
Practice Address - City:GENOA
Practice Address - State:IL
Practice Address - Zip Code:60135
Practice Address - Country:US
Practice Address - Phone:815-784-5188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036067911208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
C42656Medicare UPIN
724210Medicare ID - Type Unspecified