Provider Demographics
NPI:1689690927
Name:SANTOSA, AGNES C (MD)
Entity Type:Individual
Prefix:DR
First Name:AGNES
Middle Name:C
Last Name:SANTOSA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11241 SPENCERPORT WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131-2912
Mailing Address - Country:US
Mailing Address - Phone:858-549-9652
Mailing Address - Fax:858-549-4941
Practice Address - Street 1:11241 SPENCERPORT WAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92131-2912
Practice Address - Country:US
Practice Address - Phone:858-549-9652
Practice Address - Fax:858-549-4941
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA717352085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A717350Medicaid
CAWA71735BMedicare ID - Type Unspecified
CAWA71735AMedicare ID - Type Unspecified
CA00A717350Medicaid