Provider Demographics
NPI:1659371748
Name:DESANTIS, JEFFREY R (DPM)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:R
Last Name:DESANTIS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:JEFFREY
Other - Middle Name:R
Other - Last Name:DESANTIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:1038 E CHAPMAN AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92866-2111
Mailing Address - Country:US
Mailing Address - Phone:714-771-4191
Mailing Address - Fax:714-771-2731
Practice Address - Street 1:1038 E CHAPMAN AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92866-2111
Practice Address - Country:US
Practice Address - Phone:714-771-4191
Practice Address - Fax:714-771-2731
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3758213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E37580Medicaid
U17686Medicare UPIN
CAE3758Medicare ID - Type Unspecified