Provider Demographics
NPI:1588601389
Name:WEST PARK MEDICAL LLC
Entity type:Organization
Organization Name:WEST PARK MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDDIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTIAGO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-775-6011
Mailing Address - Street 1:780 W PARK AVE
Mailing Address - Street 2:
Mailing Address - City:OAKHURST
Mailing Address - State:NJ
Mailing Address - Zip Code:07755-1014
Mailing Address - Country:US
Mailing Address - Phone:732-775-6011
Mailing Address - Fax:
Practice Address - Street 1:780 W PARK AVE
Practice Address - Street 2:
Practice Address - City:OAKHURST
Practice Address - State:NJ
Practice Address - Zip Code:07755-1014
Practice Address - Country:US
Practice Address - Phone:732-775-6011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ097160Medicare ID - Type Unspecified