Provider Demographics
NPI:1093715260
Name:SANTIAGO AVILES, EDSON LUIS (MD)
Entity Type:Individual
Prefix:DR
First Name:EDSON
Middle Name:LUIS
Last Name:SANTIAGO AVILES
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 1:909 AVE. TITO CASTRO
Mailing Address - Street 2:SUITE 813
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00716
Mailing Address - Country:US
Mailing Address - Phone:787-259-3373
Mailing Address - Fax:787-267-3874
Practice Address - Street 1:909 AVE. TITO CASTRO
Practice Address - Street 2:SUITE 813
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00716
Practice Address - Country:US
Practice Address - Phone:787-651-1426
Practice Address - Fax:787-267-3874
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11143207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR11143OtherLICENSE
PRG40963Medicare UPIN
87655Medicare PIN