Basic Information
| Provider Information | |||||||||
| NPI: | 1972539963 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DISANDRO | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 SW 60TH CT | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331554000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056696448 | ||||||||
| FaxNumber: | 3056638485 | ||||||||
| Practice Location | |||||||||
| Address1: | 3200 SW 60TH CT | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331554000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056696448 | ||||||||
| FaxNumber: | 3056638485 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 83628 | FL | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 263295100 | 05 | FL | MEDICAID |