Provider Demographics
NPI:1265417497
Name:SANTAELLA MALDONADO, MARIO (MD)
Entity type:Individual
Prefix:MR
First Name:MARIO
Middle Name:
Last Name:SANTAELLA MALDONADO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1327
Mailing Address - Street 2:
Mailing Address - City:SAN GERMAN
Mailing Address - State:PR
Mailing Address - Zip Code:00683-1327
Mailing Address - Country:US
Mailing Address - Phone:787-873-4345
Mailing Address - Fax:787-873-1091
Practice Address - Street 1:17 CALLE BALDORIOTY
Practice Address - Street 2:
Practice Address - City:SABANA GRANDE
Practice Address - State:PR
Practice Address - Zip Code:00637
Practice Address - Country:US
Practice Address - Phone:787-873-4345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-09
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR9933207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR82697Medicare ID - Type Unspecified
F47561Medicare UPIN