Provider Demographics
NPI:1104849025
Name:SANTOS, RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:SANTOS
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 1:100 E MICHIGAN AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1406
Mailing Address - Country:US
Mailing Address - Phone:517-205-1731
Mailing Address - Fax:
Practice Address - Street 1:100 E MICHIGAN AVE STE 102
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1406
Practice Address - Country:US
Practice Address - Phone:517-205-1731
Practice Address - Fax:314-362-9878
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301112253207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207353400Medicaid
MO934860183Medicare PIN
MOP00290223Medicare PIN
MO934860183Medicaid