Provider Demographics
NPI:1740508381
Name:COLON-SANTIAGO, MARICEL (MD)
Entity type:Individual
Prefix:
First Name:MARICEL
Middle Name:
Last Name:COLON-SANTIAGO
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 1:900 S PINE ISLAND RD STE 800
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-3923
Mailing Address - Country:US
Mailing Address - Phone:561-798-9417
Mailing Address - Fax:561-798-9419
Practice Address - Street 1:1015 N STATE ROAD 7 STE D
Practice Address - Street 2:
Practice Address - City:ROYAL PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411-5185
Practice Address - Country:US
Practice Address - Phone:561-798-9417
Practice Address - Fax:561-798-9419
Is Sole Proprietor?:No
Enumeration Date:2010-05-06
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME107073208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002172600Medicaid