Provider Demographics
NPI:1700292042
Name:CASTRO SANTIAGO, MARIVIL (ARNP)
Entity Type:Individual
Prefix:
First Name:MARIVIL
Middle Name:
Last Name:CASTRO SANTIAGO
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 NW 49TH ST STE 125
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-3750
Mailing Address - Country:US
Mailing Address - Phone:954-467-0880
Mailing Address - Fax:954-525-2030
Practice Address - Street 1:1401 S FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2619
Practice Address - Country:US
Practice Address - Phone:954-728-8080
Practice Address - Fax:954-779-1957
Is Sole Proprietor?:No
Enumeration Date:2014-07-08
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9193452363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018901600Medicaid
FL018901600Medicaid