Provider Demographics
NPI:1396849931
Name:SANTOS, SHIRLEY IVELESSE (MD)
Entity type:Individual
Prefix:DR
First Name:SHIRLEY
Middle Name:IVELESSE
Last Name:SANTOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 W BASS ST
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-5001
Mailing Address - Country:US
Mailing Address - Phone:407-483-8801
Mailing Address - Fax:
Practice Address - Street 1:1000 E OSCEOLA PKWY
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-1607
Practice Address - Country:US
Practice Address - Phone:407-847-7910
Practice Address - Fax:407-932-2432
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN1031208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
H67170Medicare UPIN