Provider Demographics
NPI:1821127077
Name:EDWARD A DESANO JR MD PA
Entity Type:Organization
Organization Name:EDWARD A DESANO JR MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARSHA
Authorized Official - Middle Name:
Authorized Official - Last Name:DESANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-251-6690
Mailing Address - Street 1:2110 N MINK CREEK RD
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-7207
Mailing Address - Country:US
Mailing Address - Phone:208-251-6690
Mailing Address - Fax:
Practice Address - Street 1:755 HOSPITAL WAY
Practice Address - Street 2:B 2
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2717
Practice Address - Country:US
Practice Address - Phone:208-232-0581
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-3307207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0002460200Medicaid
ID0002460200Medicaid
D73457Medicare UPIN