Provider Demographics
NPI:1487647236
Name:SANTOS, DIANA IDALIA (MD)
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:IDALIA
Last Name:SANTOS
Suffix:
Gender:F
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:CALLE PROGRESO #14
Mailing Address - Street 2:PMB 55
Mailing Address - City:AGUADILLA
Mailing Address - State:PR
Mailing Address - Zip Code:00603-5008
Mailing Address - Country:US
Mailing Address - Phone:787-819-0194
Mailing Address - Fax:787-819-0194
Practice Address - Street 1:CALLE PROGRESO #8 ALTOS
Practice Address - Street 2:
Practice Address - City:AGUADILLA
Practice Address - State:PR
Practice Address - Zip Code:00603-5008
Practice Address - Country:US
Practice Address - Phone:787-819-0194
Practice Address - Fax:787-819-0194
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-26
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6274208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR16274OtherMCS
PR2901 1OtherPROSSAM
PR67065OtherBLUE CROSS
PR316274OtherUIA
27895Medicare ID - Type Unspecified
PRD08439Medicare UPIN