Provider Demographics
NPI:1770791741
Name:SANTIAGO M LEYTE VIDAL MD LLC
Entity type:Organization
Organization Name:SANTIAGO M LEYTE VIDAL MD LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SANTIAGO
Authorized Official - Middle Name:M
Authorized Official - Last Name:LEYTE VIDAL
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:321-783-2412
Mailing Address - Street 1:465 MINUTEMEN CSWY
Mailing Address - Street 2:
Mailing Address - City:COCOA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32931-2881
Mailing Address - Country:US
Mailing Address - Phone:321-783-2412
Mailing Address - Fax:321-784-1689
Practice Address - Street 1:465 MINUTEMEN CSWY
Practice Address - Street 2:
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931-2881
Practice Address - Country:US
Practice Address - Phone:321-783-2412
Practice Address - Fax:321-784-1689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty