Provider Demographics
NPI:1578800454
Name:BERNADETTE SANTOS MD PA
Entity Type:Organization
Organization Name:BERNADETTE SANTOS MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BERNADETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-753-0581
Mailing Address - Street 1:121A LAGRANDE BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32159-1302
Mailing Address - Country:US
Mailing Address - Phone:352-753-0581
Mailing Address - Fax:352-753-2078
Practice Address - Street 1:1503 BUENOS AIRES BLVD STE 180
Practice Address - Street 2:
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32159
Practice Address - Country:US
Practice Address - Phone:352-323-1482
Practice Address - Fax:352-259-0748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-11
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME81152208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL143942097Medicaid
FL51617OtherBLUE CROSS BLUE SHIELD PROVIDER NUMBER
FL143942097OtherTRICARE PROVIDER NUMBER
FLP00601026OtherRAILROAD MEDICARE PROVIDER NUMBER
FL143942097OtherTRICARE PROVIDER NUMBER