Provider Demographics
NPI:1619940418
Name:LEYTE VIDAL, SANTIAGO M JR (MD)
Entity Type:Individual
Prefix:DR
First Name:SANTIAGO
Middle Name:M
Last Name:LEYTE VIDAL
Suffix:JR
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 1:465 MINUTEMEN CSWY
Mailing Address - Street 2:
Mailing Address - City:COCOA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32931-2881
Mailing Address - Country:US
Mailing Address - Phone:321-783-2412
Mailing Address - Fax:321-784-1689
Practice Address - Street 1:465 MINUTEMEN CSWY
Practice Address - Street 2:
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931-2881
Practice Address - Country:US
Practice Address - Phone:321-784-0023
Practice Address - Fax:321-784-1689
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-10
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL47809207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL03639AMedicare ID - Type UnspecifiedPROVIDER NUMBER
FLD82313Medicare UPIN