Provider Demographics
NPI:1992908586
Name:DESANTO, JEFFREY R (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:R
Last Name:DESANTO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11614 N 40TH PL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-2242
Mailing Address - Country:US
Mailing Address - Phone:309-648-8207
Mailing Address - Fax:
Practice Address - Street 1:350 W. THOMAS AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013
Practice Address - Country:US
Practice Address - Phone:602-406-6281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-09
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361253212085R0202X
IL1250465272085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology