Healthcare Provider Details

I. General information

NPI: 1932300134
Provider Name (Legal Business Name): VINSON MICHAEL DISANTO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 12/09/2020
Certification Date: 12/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10725 BALD CYPRESS LN
KNOXVILLE TN
37922-6760
US

IV. Provider business mailing address

3 MAJESTIC WAY
MARLTON NJ
08053-3774
US

V. Phone/Fax

Practice location:
  • Phone: 609-760-8766
  • Fax:
Mailing address:
  • Phone: 732-542-2638
  • Fax: 732-542-2620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A5627
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number25MB07769000
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberDO0000001488
License Number StateTN
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO0000001488
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: