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General NPI Number Information
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NPI Number | 1174507594
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Entity Type | Individual
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Provider Name | MARYANNE DESANTIS MD
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Gender | Female
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Dates
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Enumeration Date | 11/30/2005
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Last Update Date | 08/01/2008
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Provider Practice Location Address
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Address Line | 375 SEGUINE AVE
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City | STATEN ISLAND
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State | NY
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Zip | 10309-3932
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Country | US
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Telephone | 718-226-2440
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Fax |
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Provider Business Mailing Address
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Address Line | 1 EDGEWATER ST 6TH FL. PAYER RELATION
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City | STATEN ISLAND
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State | NY
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Zip | 10305-4900
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Country | US
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Telephone | 718-226-1008
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Fax | 718-226-1039
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 190585
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 2084F0202X
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Taxonomy Name | Forensic Psychiatry Physician
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License Number | 190585
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License Number State | NY
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Taxonomy #3
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Taxonomy Code | 2084P0802X
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Taxonomy Name | Addiction Psychiatry Physician
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License Number | 190585
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License Number State | NY
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