Provider Demographics
NPI:1891801247
Name:BOQUE-SANTIAGO, MIGUEL J (MD)
Entity Type:Individual
Prefix:DR
First Name:MIGUEL
Middle Name:J
Last Name:BOQUE-SANTIAGO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MIGUEL
Other - Middle Name:J
Other - Last Name:BOQUE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:525 TECHNOLOGY PARK
Mailing Address - Street 2:STE 109
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-7107
Mailing Address - Country:US
Mailing Address - Phone:407-647-2346
Mailing Address - Fax:407-647-5431
Practice Address - Street 1:1390 E BURLEIGH BLVD
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-4305
Practice Address - Country:US
Practice Address - Phone:352-530-1355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR14822207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine