Provider Demographics
NPI:1275272882
Name:SANTOS MARRERO, SUSANE GRISEL
Entity Type:Individual
Prefix:
First Name:SUSANE
Middle Name:GRISEL
Last Name:SANTOS MARRERO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 3 BOX 34203
Mailing Address - Street 2:
Mailing Address - City:MOROVIS
Mailing Address - State:PR
Mailing Address - Zip Code:00687-9051
Mailing Address - Country:US
Mailing Address - Phone:787-618-3746
Mailing Address - Fax:
Practice Address - Street 1:PUERTO RICO CARR 52
Practice Address - Street 2:
Practice Address - City:CAYEY
Practice Address - State:PR
Practice Address - Zip Code:00736
Practice Address - Country:US
Practice Address - Phone:787-535-1001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-01
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR4614942Medicaid