Provider Demographics
NPI:1932109196
Name:CARRASCO-SANTIAGO, MANUEL R (MD)
Entity Type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:R
Last Name:CARRASCO-SANTIAGO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MANUEL
Other - Middle Name:R
Other - Last Name:CARRASCO-SANTIAGO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1501 W 11TH PL
Mailing Address - Street 2:SUITE # 304
Mailing Address - City:BIG SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:79720-4119
Mailing Address - Country:US
Mailing Address - Phone:432-714-4500
Mailing Address - Fax:432-714-4502
Practice Address - Street 1:1501 W 11TH PL
Practice Address - Street 2:SUITE # 304
Practice Address - City:BIG SPRING
Practice Address - State:TX
Practice Address - Zip Code:79720-4119
Practice Address - Country:US
Practice Address - Phone:432-714-4500
Practice Address - Fax:432-714-4502
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ5275207R00000X, 283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX134103409Medicaid
TX84K600Medicare PIN
TX134103409Medicaid
TXF41711Medicare UPIN