Provider Demographics
NPI:1053350223
Name:DESANTIS, ROBERT A (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:A
Last Name:DESANTIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39441-0247
Mailing Address - Country:US
Mailing Address - Phone:601-649-9904
Mailing Address - Fax:601-649-9944
Practice Address - Street 1:1203 AVE B
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39437-2080
Practice Address - Country:US
Practice Address - Phone:601-477-8553
Practice Address - Fax:601-649-9944
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL31288207V00000X
MS13169207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00119497Medicaid
G39597Medicare UPIN
MS00119497Medicaid