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General NPI Number Information
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NPI Number | 1386771749
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Entity Type | Individual
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Provider Name | PHILIP DESANTIS O.D.
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Gender | Male
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Dates
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Enumeration Date | 02/27/2007
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Last Update Date | 12/07/2010
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Provider Practice Location Address
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Address Line | 1850 SW GATLIN BLVD WALMART OPTICAL
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City | PORT SAINT LUCIE
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State | FL
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Zip | 34953-2703
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Country | US
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Telephone | 772-343-0003
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Fax | 772-336-9017
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Provider Business Mailing Address
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Address Line | 1850 SW GATLIN BLVD WALMART OPTICAL
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City | PORT SAINT LUCIE
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State | FL
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Zip | 34953-2703
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Country | US
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Telephone | 772-343-0003
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Fax | 772-336-9017
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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 | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OPC 2169
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License Number State | FL
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