Provider Demographics
NPI:1932300134
Name:DISANTO, VINSON MICHAEL (DO)
Entity Type:Individual
Prefix:DR
First Name:VINSON
Middle Name:MICHAEL
Last Name:DISANTO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 MAJESTIC WAY
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-3774
Mailing Address - Country:US
Mailing Address - Phone:732-542-2638
Mailing Address - Fax:732-542-2620
Practice Address - Street 1:10725 BALD CYPRESS LN
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37922-6760
Practice Address - Country:US
Practice Address - Phone:609-760-8766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5627207Q00000X
NJ25MB07769000207QA0505X
TNDO0000001488208D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJE42842Medicare UPIN