Provider Demographics
NPI:1346342433
Name:SANTOS, BENJAMIN MALABANAN (DPM)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:MALABANAN
Last Name:SANTOS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1237 NW SCENIC LAKE DRIVE
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055
Mailing Address - Country:US
Mailing Address - Phone:386-755-2007
Mailing Address - Fax:
Practice Address - Street 1:619 S. MARION AVE.
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025
Practice Address - Country:US
Practice Address - Phone:386-755-3016
Practice Address - Fax:386-754-6348
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36.002195213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist