Provider Demographics
NPI:1003885823
Name:DE LOS SANTOS, JUAN CARLOS (MD)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:CARLOS
Last Name:DE LOS SANTOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JUAN
Other - Middle Name:CARLOS
Other - Last Name:DE LOS SANTOS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:601 S HARBOUR ISLAND BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-5925
Mailing Address - Country:US
Mailing Address - Phone:800-480-5243
Mailing Address - Fax:800-928-7449
Practice Address - Street 1:194 MARION OAKS BLVD
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34473-2215
Practice Address - Country:US
Practice Address - Phone:352-421-3550
Practice Address - Fax:844-388-6186
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-15
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR14911208D00000X
FLACN373208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR22231Medicare ID - Type UnspecifiedNUMERO DE PROVEEDOR MEDIC