Provider Demographics
NPI:1265622252
Name:SANTIAGO, ILDEFONSO
Entity type:Individual
Prefix:
First Name:ILDEFONSO
Middle Name:
Last Name:SANTIAGO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MELIFE
Other - Middle Name:
Other - Last Name:AMBULANCE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:P O BOX 1847
Mailing Address - Street 2:
Mailing Address - City:CABO ROJO
Mailing Address - State:PR
Mailing Address - Zip Code:00623-1847
Mailing Address - Country:US
Mailing Address - Phone:787-255-0636
Mailing Address - Fax:787-851-2697
Practice Address - Street 1:100 CALLE PARQUE W
Practice Address - Street 2:
Practice Address - City:CABO ROJO
Practice Address - State:PR
Practice Address - Zip Code:00623-3735
Practice Address - Country:US
Practice Address - Phone:787-255-0636
Practice Address - Fax:787-851-2697
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-26
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PRTC AMB 310341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0056627Medicare PIN
0056627Medicare PIN