Provider Demographics
NPI:1700914371
Name:DIAZ, SANTIAGO SANTIAGO
Entity Type:Individual
Prefix:DR
First Name:SANTIAGO
Middle Name:SANTIAGO
Last Name:DIAZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 697
Mailing Address - Street 2:
Mailing Address - City:PATILLAS
Mailing Address - State:PR
Mailing Address - Zip Code:00723-0697
Mailing Address - Country:US
Mailing Address - Phone:787-839-4320
Mailing Address - Fax:787-271-0004
Practice Address - Street 1:99 CALLE RIEFKHOL
Practice Address - Street 2:
Practice Address - City:PATILLAS
Practice Address - State:PR
Practice Address - Zip Code:00723
Practice Address - Country:US
Practice Address - Phone:787-839-4320
Practice Address - Fax:787-271-0004
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5676208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRD08394Medicare UPIN