Provider Demographics
NPI:1134629264
Name:RODRIGUEZ SANTIAGO, SAMUEL
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:RODRIGUEZ SANTIAGO
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:SABANERA DEL RIO
Mailing Address - Street 2:282 CAMINO DEL MANGO
Mailing Address - City:GURABO
Mailing Address - State:PR
Mailing Address - Zip Code:00778
Mailing Address - Country:US
Mailing Address - Phone:787-385-7444
Mailing Address - Fax:787-385-7444
Practice Address - Street 1:BARRIO MONACILLOS
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00935-0001
Practice Address - Country:US
Practice Address - Phone:787-777-3535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-15
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6150196390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program