Provider Demographics
NPI:1952539223
Name:GONZALEZ SANTIAGO, TANIA MARIE (MD)
Entity Type:Individual
Prefix:
First Name:TANIA
Middle Name:MARIE
Last Name:GONZALEZ SANTIAGO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TANIA
Other - Middle Name:
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 6106
Mailing Address - Street 2:
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00726-6106
Mailing Address - Country:US
Mailing Address - Phone:787-346-3376
Mailing Address - Fax:
Practice Address - Street 1:201 AVE GAUTIER BENITEZ
Practice Address - Street 2:STE 405A CONSOLIDATED MEDICAL MALL
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00726
Practice Address - Country:US
Practice Address - Phone:787-346-3376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN105584207N00000X
MN54430207N00000X
NDLT15015207N00000X, 207N00000X
PR22836207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAENROLLEDMedicaid
MNENROLLEDMedicaid
PR039370300Medicaid
FL015047800Medicaid
FLIE905ZMedicare PIN