Provider Demographics
NPI:1356450985
Name:SANTOS, ROMAN NICOLAS (MD)
Entity Type:Individual
Prefix:
First Name:ROMAN
Middle Name:NICOLAS
Last Name:SANTOS
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 1:69 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02347-3628
Mailing Address - Country:US
Mailing Address - Phone:508-947-4400
Mailing Address - Fax:508-946-1610
Practice Address - Street 1:69 MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MA
Practice Address - Zip Code:02347-3628
Practice Address - Country:US
Practice Address - Phone:508-947-4400
Practice Address - Fax:508-946-1610
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2009-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA53465207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3008657Medicaid
MAB99193Medicare UPIN
MA3008657Medicaid