Provider Demographics
NPI:1265821094
Name:LOURDES T SANTIAGO M.D.P.A.
Entity Type:Organization
Organization Name:LOURDES T SANTIAGO M.D.P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:LOURDES
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTIAGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-483-9188
Mailing Address - Street 1:1305 S FORT HARRISON AVE
Mailing Address - Street 2:BUILDING C
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33756-3301
Mailing Address - Country:US
Mailing Address - Phone:727-483-9188
Mailing Address - Fax:727-412-8432
Practice Address - Street 1:1305 S FORT HARRISON AVE
Practice Address - Street 2:BUILDING C
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-3301
Practice Address - Country:US
Practice Address - Phone:727-483-9188
Practice Address - Fax:727-412-8432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-16
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME97611261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL277873400Medicaid