Healthcare Provider Details

I. General information

NPI: 1174507594
Provider Name (Legal Business Name): MARYANNE DESANTIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 08/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 SEGUINE AVE
STATEN ISLAND NY
10309-3932
US

IV. Provider business mailing address

1 EDGEWATER ST 6TH FL. PAYER RELATION
STATEN ISLAND NY
10305-4900
US

V. Phone/Fax

Practice location:
  • Phone: 718-226-2440
  • Fax:
Mailing address:
  • Phone: 718-226-1008
  • Fax: 718-226-1039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number190585
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License Number190585
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number190585
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: