Provider Demographics
NPI:1881845782
Name:MEDINA, SANTIAGO ELI
Entity Type:Individual
Prefix:DR
First Name:SANTIAGO
Middle Name:ELI
Last Name:MEDINA
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:LE93 VIA PARIS
Mailing Address - Street 2:L ANTIGUA
Mailing Address - City:TRUJILLO ALTO
Mailing Address - State:PR
Mailing Address - Zip Code:00976-5414
Mailing Address - Country:US
Mailing Address - Phone:787-585-4917
Mailing Address - Fax:
Practice Address - Street 1:CARR 844 KM 4.2
Practice Address - Street 2:CUPEY BAJO
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00926
Practice Address - Country:US
Practice Address - Phone:787-760-0770
Practice Address - Fax:787-998-4415
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-09
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR17361208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR17361OtherSTATE LICENSE