Provider Demographics
NPI:1770132433
Name:DE LOS SANTOS, KARIZ MAE GALANO
Entity type:Individual
Prefix:
First Name:KARIZ MAE
Middle Name:GALANO
Last Name:DE LOS SANTOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6805 FRESH POND RD
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-5200
Mailing Address - Country:US
Mailing Address - Phone:718-456-2543
Mailing Address - Fax:718-799-9191
Practice Address - Street 1:8742 PARSONS BLVD
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-3317
Practice Address - Country:US
Practice Address - Phone:718-456-2543
Practice Address - Fax:718-559-6784
Is Sole Proprietor?:No
Enumeration Date:2019-09-05
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041138-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist