Provider Demographics
NPI:1255318598
Name:SANTIAGO MEDINA, SANTOS (MD)
Entity Type:Individual
Prefix:
First Name:SANTOS
Middle Name:
Last Name:SANTIAGO MEDINA
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:PO BOX 800378
Mailing Address - Street 2:
Mailing Address - City:COTO LAUREL
Mailing Address - State:PR
Mailing Address - Zip Code:00780-0378
Mailing Address - Country:US
Mailing Address - Phone:787-841-1141
Mailing Address - Fax:787-841-1142
Practice Address - Street 1:AVE LAS AMERICAS 2401
Practice Address - Street 2:EDIFICIO PORRATA PILA #207
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00717-2115
Practice Address - Country:US
Practice Address - Phone:787-841-1141
Practice Address - Fax:787-841-1142
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6223207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
7330017OtherHUMANA
209302OtherUTI
600090OtherMMM
6424OtherIMC
PE 3807OtherPALIC
067249OtherCRUZ AZUL
3706223OtherUIA
80918OtherTRIPLE S
600090OtherMMM
PE 3807OtherPALIC