Provider Demographics
NPI:1720174501
Name:DISANTO, DAVID J (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:J
Last Name:DISANTO
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2464 PAWTUCKET AVENUE
Mailing Address - Street 2:
Mailing Address - City:EAST PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02914
Mailing Address - Country:US
Mailing Address - Phone:401-431-0226
Mailing Address - Fax:401-434-3166
Practice Address - Street 1:2464 PAWTUCKET AVENUE
Practice Address - Street 2:
Practice Address - City:EAST PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02914
Practice Address - Country:US
Practice Address - Phone:401-431-0226
Practice Address - Fax:401-434-3166
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2025-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI5417174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI002602OtherBLUE CHIP
MADAM13785OtherMA BLUE CROSS
RI06-00102OtherUNHP
RI1603-8OtherBLUE CROSS
RI9001603Medicaid
RI9001603Medicaid