Provider Demographics
NPI:1730135492
Name:DESANTIS, ANNETTE G (MD)
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:G
Last Name:DESANTIS
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:1420 STEPHENSON HWY
Mailing Address - Street 2:SUITE 400--CREDENTIALING
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1189
Mailing Address - Country:US
Mailing Address - Phone:248-581-5974
Mailing Address - Fax:248-581-5640
Practice Address - Street 1:18181 OAKWOOD BLVD
Practice Address - Street 2:SUITE 411
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-5032
Practice Address - Country:US
Practice Address - Phone:313-438-7373
Practice Address - Fax:313-438-7375
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2013-11-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MIAD042312208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
2505035481OtherBCBS
B45256Medicare UPIN
2505035481OtherBCBS