Provider Demographics
NPI:1932358009
Name:LABAULT-SANTIAGO, JOSE RAFAEL (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:RAFAEL
Last Name:LABAULT-SANTIAGO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5700 LAKE WORTH RD
Mailing Address - Street 2:STE 204
Mailing Address - City:GREENACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33463-4727
Mailing Address - Country:US
Mailing Address - Phone:561-966-7707
Mailing Address - Fax:
Practice Address - Street 1:140 JFK DR
Practice Address - Street 2:
Practice Address - City:ATLANTIS
Practice Address - State:FL
Practice Address - Zip Code:33462-6608
Practice Address - Country:US
Practice Address - Phone:561-968-6767
Practice Address - Fax:561-641-0814
Is Sole Proprietor?:No
Enumeration Date:2008-09-15
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP33752084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14W87OtherBCBS
FLHY573ZMedicare PIN