Provider Demographics
NPI:1386624443
Name:DE SANTIS, TIMOTHY QUINN (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:QUINN
Last Name:DE SANTIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2900 CORPORATE AVE
Mailing Address - Street 2:DOOR D
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-3925
Mailing Address - Country:US
Mailing Address - Phone:954-276-5685
Mailing Address - Fax:954-985-7074
Practice Address - Street 1:3501 JOHNSON ST FL 2
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-5421
Practice Address - Country:US
Practice Address - Phone:954-265-3441
Practice Address - Fax:954-368-0195
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME73376207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL252494500Medicaid
FL41562ZMedicare PIN
FL41562OtherBCBS