Provider Demographics
NPI:1952371007
Name:DESANTIS, NANCY M (DO)
Entity Type:Individual
Prefix:DR
First Name:NANCY
Middle Name:M
Last Name:DESANTIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33717 WOODWARD AVENUE
Mailing Address - Street 2:SUITE 416
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009
Mailing Address - Country:US
Mailing Address - Phone:248-809-1227
Mailing Address - Fax:248-809-1228
Practice Address - Street 1:3601 W 13 MILE ROAD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073
Practice Address - Country:US
Practice Address - Phone:248-809-1227
Practice Address - Fax:248-809-1228
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011544208100000X
MIND011544208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4166178Medicaid
E92648Medicare UPIN
MIE92648Medicare UPIN
MI4166178Medicaid
MI0M95070Medicare PIN