Provider Demographics
NPI:1720010648
Name:SANTOSO, JOSEPH T (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:T
Last Name:SANTOSO
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 1:965 RIDGE LAKE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9446
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:901-227-8591
Practice Address - Street 1:80 HUMPHREYS CENTER DR STE 202
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2361
Practice Address - Country:US
Practice Address - Phone:901-226-4280
Practice Address - Fax:901-226-4282
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18309207VX0201X
TN34845207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR145192001Medicaid
TN3859812Medicaid
TN4098941OtherBCBS TN
MO205296718Medicaid
5956489OtherAETNA
AR99295OtherBCBS AR
MS00123467Medicaid
MSP00207556Medicare PIN
TN3859812Medicaid
MS00123467Medicaid
AR99295OtherBCBS AR