Provider Demographics
NPI:1639177991
Name:DIAZ SANTANA, PEDRO (MD)
Entity Type:Individual
Prefix:
First Name:PEDRO
Middle Name:
Last Name:DIAZ SANTANA
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 1:10710 MCPHERSON RD
Mailing Address - Street 2:SUITE # 105
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78045-6271
Mailing Address - Country:US
Mailing Address - Phone:956-717-2328
Mailing Address - Fax:956-717-2395
Practice Address - Street 1:10710 MCPHERSON RD
Practice Address - Street 2:SUITE # 105
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78045
Practice Address - Country:US
Practice Address - Phone:956-717-2328
Practice Address - Fax:956-717-2395
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-11
Last Update Date:2023-03-07
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-30
Provider Licenses
StateLicense IDTaxonomies
PR10030207RC0000X
TXN1305207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0058RROtherBLUE CROSS BLUES SHIELD
BD4669581OtherDEA
PR0087986Medicare ID - Type UnspecifiedMEDICARE
0087986Medicare PIN
PRG32924Medicare UPIN