Provider Demographics
NPI:1659326650
Name:DESANTIS, JAMES M (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:M
Last Name:DESANTIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:10247 HIGHWAY 92
Mailing Address - Street 2:APT 402
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-3914
Mailing Address - Country:US
Mailing Address - Phone:678-361-3028
Mailing Address - Fax:
Practice Address - Street 1:400 WESTPARK CT
Practice Address - Street 2:STE 230
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-3571
Practice Address - Country:US
Practice Address - Phone:770-631-8478
Practice Address - Fax:770-631-8473
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AL25650207P00000X
PAMD027124E207P00000X
TXP1452207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL4295661OtherAETNA
10577706OtherCAQH
AL009912277Medicaid
AL051542232OtherBCBS
ALC87440Medicare UPIN
10577706OtherCAQH