Provider Demographics
NPI:1932595485
Name:DESANTIS, ELIZA CAROLINE (MD)
Entity Type:Individual
Prefix:
First Name:ELIZA
Middle Name:CAROLINE
Last Name:DESANTIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELIZA
Other - Middle Name:CAROLINE
Other - Last Name:FRADKIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:833 CHESTNUT ST STE 1210
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4428
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:833 CHESTNUT ST STE 1210
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4428
Practice Address - Country:US
Practice Address - Phone:215-955-2074
Practice Address - Fax:215-861-0408
Is Sole Proprietor?:No
Enumeration Date:2015-04-11
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD464274208000000X
PAMT2089532080N0001X
DEC7-000071862080N0001X
NJ25MA10378300208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEC7-0005869OtherDE TRAINING LICENSE