Provider Demographics
NPI:1952346249
Name:DESANTIS, DIANA MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANA
Middle Name:MARIE
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 1:4875 WARD ROAD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033
Mailing Address - Country:US
Mailing Address - Phone:303-456-9456
Mailing Address - Fax:303-463-7560
Practice Address - Street 1:4875 WARD ROAD
Practice Address - Street 2:SUITE 600
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033
Practice Address - Country:US
Practice Address - Phone:303-456-9456
Practice Address - Fax:303-463-7560
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2018-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO31859207W00000X
CODR.0031859207WX0110X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0110XAllopathic & Osteopathic PhysiciansOphthalmologyPediatric Ophthalmology and Strabismus Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01318591Medicaid
CO1318591Medicaid
COE90144Medicare UPIN
COF2328Medicare ID - Type Unspecified
CO01318591Medicaid