Provider Demographics
NPI:1821865577
Name:SANTIESTEBAN, ELIAS JORGE
Entity Type:Individual
Prefix:
First Name:ELIAS
Middle Name:JORGE
Last Name:SANTIESTEBAN
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 1:33463 SW 197TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33034-1509
Mailing Address - Country:US
Mailing Address - Phone:786-255-8977
Mailing Address - Fax:
Practice Address - Street 1:1408 NE 1ST AVE
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-4535
Practice Address - Country:US
Practice Address - Phone:305-242-1399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12499224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty