Provider Demographics
NPI:1568446672
Name:SANTIBANEZ, JORGE (MD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:SANTIBANEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JORGE
Other - Middle Name:
Other - Last Name:SANTIBANEZ -BANDALA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 3299
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89702-3299
Mailing Address - Country:US
Mailing Address - Phone:775-222-0044
Mailing Address - Fax:888-700-0187
Practice Address - Street 1:1600 MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89703-4625
Practice Address - Country:US
Practice Address - Phone:775-445-8795
Practice Address - Fax:775-445-5175
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2017-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD24602207R00000X
NV13739208M00000X
UT7746287-1205208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR227344Medicaid
ORR150705Medicare PIN
H93823Medicare UPIN