Provider Demographics
NPI:1619419165
Name:SANTIAGO, LUIS MIGUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:MIGUEL
Last Name:SANTIAGO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1714 CALLE TINTO
Mailing Address - Street 2:RIO PIEDRAS HEIGHTS
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-3251
Mailing Address - Country:US
Mailing Address - Phone:787-630-9892
Mailing Address - Fax:
Practice Address - Street 1:8880 ROYAL PALM BLVD STE 100
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33065-5727
Practice Address - Country:US
Practice Address - Phone:954-753-2411
Practice Address - Fax:954-753-1176
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-15
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME148375207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME148375OtherMEDICAL LICENSE