MEDICARE: JO C DESANTIS MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	181242	NY

General Provider Information

NPI Number	:	1336234350
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JO C DESANTIS MD

Provider Business Mailing Address
First Line	:	75 VANDERBILT AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10304-2604
Country	:	US
Telephone Number	:	718-818-5385
Fax Number	:

Provider Business Practice Location Address
First Line	:	75 VANDERBILT AVE
Second Line	:	CONTINUING DAY TREATMENT
City	:	STATEN ISLAND
State	:	NY
Zip	:	10304-2604
Country	:	US
Telephone Number	:	718-181-5385
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	06/04/2012

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