Provider Demographics
NPI:1013103332
Name:SANTOS, CHARITO M (MD)
Entity Type:Individual
Prefix:
First Name:CHARITO
Middle Name:M
Last Name:SANTOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CHARITO
Other - Middle Name:B
Other - Last Name:SANTOS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:13819 HANSON BLVD NW
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-7608
Mailing Address - Country:US
Mailing Address - Phone:763-392-4001
Mailing Address - Fax:
Practice Address - Street 1:13819 HANSON BLVD NW
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-7608
Practice Address - Country:US
Practice Address - Phone:763-392-4001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-20
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI54594207P00000X, 207Q00000X
PAMT189896207Q00000X
MN58448207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1013103332Medicaid