Provider Demographics
NPI:1902091036
Name:DESANTIS, MARTIN JOHN (DO)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:JOHN
Last Name:DESANTIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17046-5040
Mailing Address - Country:US
Mailing Address - Phone:717-272-5464
Mailing Address - Fax:717-273-1416
Practice Address - Street 1:125 S 5TH ST
Practice Address - Street 2:
Practice Address - City:READING
Practice Address - State:PA
Practice Address - Zip Code:19602-1662
Practice Address - Country:US
Practice Address - Phone:610-685-2188
Practice Address - Fax:610-685-2183
Is Sole Proprietor?:No
Enumeration Date:2007-09-12
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS0156682084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102621640Medicaid
PA102621640Medicaid