Provider Demographics
NPI:1568784783
Name:SANTANA, FIDEL ANTONIO
Entity Type:Individual
Prefix:MR
First Name:FIDEL
Middle Name:ANTONIO
Last Name:SANTANA
Suffix:
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 1:79 CALLE PARQUE E
Mailing Address - Street 2:
Mailing Address - City:CABO ROJO
Mailing Address - State:PR
Mailing Address - Zip Code:00623-3707
Mailing Address - Country:US
Mailing Address - Phone:787-357-7210
Mailing Address - Fax:
Practice Address - Street 1:CALLE PARQUE#79 BO MONTE GRANDE
Practice Address - Street 2:
Practice Address - City:CABO ROJO
Practice Address - State:PR
Practice Address - Zip Code:00623
Practice Address - Country:US
Practice Address - Phone:787-357-7210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-16
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR261Q00000X261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center