Healthcare Provider Details

I. General information

NPI: 1477085793
Provider Name (Legal Business Name): DESANTO CLINICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2017
Last Update Date: 03/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 E 17TH ST SUITE 200
COSTA MESA CA
92627-3824
US

IV. Provider business mailing address

230 E 17TH ST SUITE 200
COSTA MESA CA
92627-3824
US

V. Phone/Fax

Practice location:
  • Phone: 626-616-6183
  • Fax:
Mailing address:
  • Phone: 626-616-6183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License NumberG081151
License Number StateCA

VIII. Authorized Official

Name: DR. JOSEPH DESANTO
Title or Position: OWNER
Credential: MD
Phone: 626-616-6183