Provider Demographics
NPI:1649536160
Name:SANTIAGO CHAMORRO, DIANA M (MD)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:M
Last Name:SANTIAGO CHAMORRO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:M
Other - Last Name:SANTIAGO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:11645 BISCAYNE BLVD STE 207
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33181-3138
Mailing Address - Country:US
Mailing Address - Phone:305-538-8835
Mailing Address - Fax:305-994-0054
Practice Address - Street 1:11645 BISCAYNE BLVD # 305307
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33181-3155
Practice Address - Country:US
Practice Address - Phone:305-538-8835
Practice Address - Fax:305-994-0054
Is Sole Proprietor?:No
Enumeration Date:2012-04-10
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ9023207V00000X
FLME146120207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL107545100Medicaid