Provider Demographics
NPI:1083026140
Name:MAURICE, DAMEK SANTIAGO
Entity Type:Individual
Prefix:MR
First Name:DAMEK
Middle Name:SANTIAGO
Last Name:MAURICE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1640 OLD PECOS TRL STE H
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4777
Mailing Address - Country:US
Mailing Address - Phone:505-992-0233
Mailing Address - Fax:
Practice Address - Street 1:CHRISTUS ST. VINCENT REGIONAL MEDICAL CENTER
Practice Address - Street 2:455 ST. MICHAELS DRIVE
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505
Practice Address - Country:US
Practice Address - Phone:505-913-3934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-23
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA225519207P00000X
NY63756390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty