Provider Demographics
NPI:1881704682
Name:DESANTIS, ANGELA (MD)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
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 1:3200 GREENFIELD RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48120-1802
Mailing Address - Country:US
Mailing Address - Phone:313-563-3332
Mailing Address - Fax:313-563-3342
Practice Address - Street 1:1700 BIDDLE AVE
Practice Address - Street 2:
Practice Address - City:WYANDOTTE
Practice Address - State:MI
Practice Address - Zip Code:48192-7205
Practice Address - Country:US
Practice Address - Phone:734-284-2026
Practice Address - Fax:734-284-8335
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301052721207RC0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI297792310Medicaid
MI110H211300OtherBCBS MI
MI297792310Medicaid
MI0M69960001Medicare PIN