Provider Demographics
NPI:1043484231
Name:SANTIAGO CAMACHO, MYRNA
Entity Type:Individual
Prefix:
First Name:MYRNA
Middle Name:
Last Name:SANTIAGO CAMACHO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LABORATORIO CLINICO
Other - Middle Name:HERMANAS
Other - Last Name:DAVILA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 51527
Mailing Address - Street 2:
Mailing Address - City:TOA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00950-1527
Mailing Address - Country:US
Mailing Address - Phone:787-780-8000
Mailing Address - Fax:787-740-7149
Practice Address - Street 1:121 AVE BETANCES URB HERMANAS DAVILA
Practice Address - Street 2:
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00959
Practice Address - Country:US
Practice Address - Phone:787-780-8000
Practice Address - Fax:787-740-7149
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-17
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR659291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR30513OtherTRIPLE-S
PR0038299Medicare PIN