Provider Demographics
NPI:1306813845
Name:LARDIZABAL, SANTIAGO L (MD)
Entity Type:Individual
Prefix:DR
First Name:SANTIAGO
Middle Name:L
Last Name:LARDIZABAL
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 7640
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374
Mailing Address - Country:US
Mailing Address - Phone:623-584-9985
Mailing Address - Fax:623-584-9986
Practice Address - Street 1:19424 N RH JOHNSON BLVD
Practice Address - Street 2:
Practice Address - City:SUN CITY WEST
Practice Address - State:AZ
Practice Address - Zip Code:85375
Practice Address - Country:US
Practice Address - Phone:623-584-9985
Practice Address - Fax:623-584-9986
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14445207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ239427Medicaid
AZ239427Medicaid
C99839Medicare UPIN