Provider Demographics
NPI:1629858782
Name:IRIZARRI SANTOS, JUAN
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:IRIZARRI SANTOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 TIMBERLINE DR
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-6813
Mailing Address - Country:US
Mailing Address - Phone:631-456-7907
Mailing Address - Fax:
Practice Address - Street 1:200 TIMBERLINE DR
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-6813
Practice Address - Country:US
Practice Address - Phone:631-456-7907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-04
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY250107710344600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes344600000XTransportation ServicesTaxi