Provider Demographics
NPI:1518155209
Name:SANTA, IVELISSE (MD)
Entity Type:Individual
Prefix:
First Name:IVELISSE
Middle Name:
Last Name:SANTA
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:RR 2 BOX 7054
Mailing Address - Street 2:
Mailing Address - City:MANATI
Mailing Address - State:PR
Mailing Address - Zip Code:00674-9657
Mailing Address - Country:US
Mailing Address - Phone:787-621-7558
Mailing Address - Fax:
Practice Address - Street 1:RR 2 BOX 7054
Practice Address - Street 2:
Practice Address - City:MANATI
Practice Address - State:PR
Practice Address - Zip Code:00674-9657
Practice Address - Country:US
Practice Address - Phone:787-621-7558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-09
Last Update Date:2015-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR16874208D00000X, 207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine