Provider Demographics
NPI:1720066889
Name:DESANTIS, JOAN C (MD)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:C
Last Name:DESANTIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 CARRUTH RD
Mailing Address - Street 2:
Mailing Address - City:TEMPLETON
Mailing Address - State:MA
Mailing Address - Zip Code:01468-1312
Mailing Address - Country:US
Mailing Address - Phone:978-632-7383
Mailing Address - Fax:
Practice Address - Street 1:111 BREWSTER ST
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-4400
Practice Address - Country:US
Practice Address - Phone:401-729-2339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-08
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH194042085R0202X
VT042.00129582085R0202X
RIMD119442085R0202X
MA747972085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI007058150OtherMEDICARE PTAN
MA2022419Medicaid
RIJD51209Medicaid
MAA36154Medicare ID - Type Unspecified