Provider Demographics
NPI:1639163819
Name:DESANTO, GREGORY L (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:L
Last Name:DESANTO
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 1:11209 N TATUM BLVD
Mailing Address - Street 2:#255
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-3091
Mailing Address - Country:US
Mailing Address - Phone:602-494-5050
Mailing Address - Fax:602-494-2611
Practice Address - Street 1:11209 N TATUM BLVD
Practice Address - Street 2:#255
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-3091
Practice Address - Country:US
Practice Address - Phone:602-494-5050
Practice Address - Fax:602-494-2611
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ19465207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ046591Medicaid
AZ67305Medicare ID - Type Unspecified
AZ046591Medicaid