Provider Demographics
NPI:1649280918
Name:SANTANA-PORBEN, IDALMIS (MD)
Entity type:Individual
Prefix:
First Name:IDALMIS
Middle Name:
Last Name:SANTANA-PORBEN
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 1:6101 BLUE LAGOON DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-3168
Mailing Address - Country:US
Mailing Address - Phone:786-243-5900
Mailing Address - Fax:786-243-5933
Practice Address - Street 1:15516 SW 88TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33196-1554
Practice Address - Country:US
Practice Address - Phone:305-387-3300
Practice Address - Fax:888-857-3579
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME88244207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU4955YMedicare PIN
I31986Medicare UPIN