Provider Demographics
NPI:1609836683
Name:SANTELICES, PAMELA G (MD)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:G
Last Name:SANTELICES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:PAMELA
Other - Middle Name:MONTESINO
Other - Last Name:GELLECANAO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1859 SW NEWLAND WAY
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-6966
Mailing Address - Country:US
Mailing Address - Phone:386-758-0003
Mailing Address - Fax:386-755-7940
Practice Address - Street 1:1859 SW NEWLAND WAY
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-6966
Practice Address - Country:US
Practice Address - Phone:386-758-0003
Practice Address - Fax:386-755-7940
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME80098208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL58641OtherBCBS
FL259783700Medicaid
275981OtherAVMED
FL259783700Medicaid
FL58641OtherBCBS