Healthcare Provider Details

I. General information

NPI: 1053317545
Provider Name (Legal Business Name): NICHOLAS NELSON DESANTIS D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 06/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2306 6TH AVE
SAN DIEGO CA
92101-1643
US

IV. Provider business mailing address

2306 6TH AVE
SAN DIEGO CA
92101-1643
US

V. Phone/Fax

Practice location:
  • Phone: 619-239-3286
  • Fax: 619-239-0172
Mailing address:
  • Phone: 619-239-3286
  • Fax: 619-239-0172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE2474
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: