MEDICARE: DR. NICHOLAS NELSON DESANTIS D.P.M.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213ES0103X	Foot & Ankle Surgery Podiatrist	E2474	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000E24740	OTHER	CA	BLUE CROSS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053317545
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NICHOLAS NELSON DESANTIS D.P.M.

Provider Business Mailing Address
First Line	:	2306 6TH AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92101-1643
Country	:	US
Telephone Number	:	619-239-3286
Fax Number	:	619-239-0172

Provider Business Practice Location Address
First Line	:	2306 6TH AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92101-1643
Country	:	US
Telephone Number	:	619-239-3286
Fax Number	:	619-239-0172

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/21/2005
Last Update Date	:	06/07/2013

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