Provider Demographics
NPI:1386771749
Name:DESANTIS, PHILIP (OD)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:DESANTIS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 SW GATLIN BLVD
Mailing Address - Street 2:WALMART OPTICAL
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-2703
Mailing Address - Country:US
Mailing Address - Phone:772-343-0003
Mailing Address - Fax:772-336-9017
Practice Address - Street 1:1850 SW GATLIN BLVD
Practice Address - Street 2:WALMART OPTICAL
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-2703
Practice Address - Country:US
Practice Address - Phone:772-343-0003
Practice Address - Fax:772-336-9017
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 2169152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL19821AMedicare ID - Type Unspecified
U11422Medicare UPIN