Healthcare Provider Details

I. General information

NPI: 1720010648
Provider Name (Legal Business Name): JOSEPH T SANTOSO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 12/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 HUMPHREYS CENTER DR STE 202
MEMPHIS TN
38120-2361
US

IV. Provider business mailing address

965 RIDGE LAKE BLVD STE 103
MEMPHIS TN
38120-9446
US

V. Phone/Fax

Practice location:
  • Phone: 901-226-4280
  • Fax: 901-226-4282
Mailing address:
  • Phone:
  • Fax: 901-227-8591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number18309
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number34845
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: