Provider Demographics
NPI:1457396590
Name:DISANTO, LISA M (DO)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:DISANTO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:6735 CROSSWINDS DR N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-5471
Mailing Address - Country:US
Mailing Address - Phone:727-548-8500
Mailing Address - Fax:727-501-7328
Practice Address - Street 1:6735 CROSSWINDS DR N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-5471
Practice Address - Country:US
Practice Address - Phone:727-548-8500
Practice Address - Fax:727-501-7328
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-20
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0005732207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL373788800Medicaid
FL6116740OtherCIGNA
FL276781OtherAVMED
FL80353OtherFLORIDA BLUE
FL80353WMedicare PIN
FL6116740OtherCIGNA