Provider Demographics
NPI:1467206060
Name:SANTIAGO, JESUS ANTONIO JR
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:ANTONIO
Last Name:SANTIAGO
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1380 CANARY ISLAND DR
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33327-2347
Mailing Address - Country:US
Mailing Address - Phone:787-447-0054
Mailing Address - Fax:
Practice Address - Street 1:336 E HANES MILL RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27105-9135
Practice Address - Country:US
Practice Address - Phone:336-450-2077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-11
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty