Provider Demographics
NPI:1467499285
Name:SANTANDER, JORGE LUIS (MD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:LUIS
Last Name:SANTANDER
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 1:4080 SW 84TH AVE
Mailing Address - Street 2:STE D
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-4201
Mailing Address - Country:US
Mailing Address - Phone:305-223-1140
Mailing Address - Fax:305-223-1174
Practice Address - Street 1:4080 SW 84TH AVE
Practice Address - Street 2:STE D
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-4201
Practice Address - Country:US
Practice Address - Phone:305-223-1140
Practice Address - Fax:305-223-1174
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME83255207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL262741800Medicaid
FLH53127Medicare UPIN
FLE6648UMedicare PIN