Provider Demographics
NPI:1891778338
Name:DESANTIS, MELISSA M (MD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:M
Last Name:DESANTIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:M
Other - Last Name:URIBES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1540 MAPLE RD
Mailing Address - Street 2:MILLARD FILLMORE SUBURBAN HOSPITAL
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-3647
Mailing Address - Country:US
Mailing Address - Phone:716-568-3600
Mailing Address - Fax:
Practice Address - Street 1:1540 MAPLE RD
Practice Address - Street 2:MILLARD FILLMORE SUBURBAN HOSPITAL
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-3647
Practice Address - Country:US
Practice Address - Phone:716-568-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-29
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036113230207PE0004X
NY284567207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04445492Medicaid
ILI11195Medicare UPIN