Provider Demographics
NPI:1235194309
Name:CASANOVA, SANTIAGO A JR (PT)
Entity Type:Individual
Prefix:
First Name:SANTIAGO
Middle Name:A
Last Name:CASANOVA
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4880 W NEWBERRY RD
Mailing Address - Street 2:SUITE 180
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32607-5214
Mailing Address - Country:US
Mailing Address - Phone:352-331-3161
Mailing Address - Fax:
Practice Address - Street 1:4880 W NEWBERRY RD
Practice Address - Street 2:SUITE 180
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-6652
Practice Address - Country:US
Practice Address - Phone:352-331-3161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT4768208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY3348OtherBLUE CROSS BLUE SHIELD
FLY3348ZMedicare ID - Type Unspecified