Provider Demographics
NPI:1225161508
Name:DE RUIZ, CARMEN SANTIAGO (MD)
Entity Type:Individual
Prefix:DR
First Name:CARMEN
Middle Name:SANTIAGO
Last Name:DE RUIZ
Suffix:
Gender:F
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:PO BOX 84
Mailing Address - Street 2:
Mailing Address - City:MANATI
Mailing Address - State:PR
Mailing Address - Zip Code:00674-0084
Mailing Address - Country:US
Mailing Address - Phone:787-854-5473
Mailing Address - Fax:787-854-3939
Practice Address - Street 1:VILLA MARIA B-1
Practice Address - Street 2:
Practice Address - City:MANATI
Practice Address - State:PR
Practice Address - Zip Code:00674-4924
Practice Address - Country:US
Practice Address - Phone:787-854-5473
Practice Address - Fax:787-854-3939
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5218174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR5218OtherLICENSE
PR0025110Medicare PIN
PR5218OtherLICENSE