Provider Demographics
NPI:1144774076
Name:SANTIAGO, PEDRO JUAN
Entity Type:Individual
Prefix:
First Name:PEDRO
Middle Name:JUAN
Last Name:SANTIAGO
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:M35 CALLE WILSON
Mailing Address - Street 2:URB. PARKVILLE
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00969-3950
Mailing Address - Country:US
Mailing Address - Phone:787-607-6985
Mailing Address - Fax:787-395-7816
Practice Address - Street 1:39 CALLE BETANCES
Practice Address - Street 2:PUEBLO
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00961-6207
Practice Address - Country:US
Practice Address - Phone:787-395-7816
Practice Address - Fax:787-395-7816
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-09
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1344291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR40D2104058OtherCMS