Healthcare Provider Details

I. General information

NPI: 1518003326
Provider Name (Legal Business Name): ROBERT SAMUEL DESANTIS ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 05/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4258 67TH AVENUE CIR E
SARASOTA FL
34243-5101
US

IV. Provider business mailing address

4258 67TH AVENUE CIR E
SARASOTA FL
34243-5101
US

V. Phone/Fax

Practice location:
  • Phone: 941-993-9606
  • Fax:
Mailing address:
  • Phone: 941-993-9606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberAL-1309
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL1309
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: