1790755759 NPI number — SANTIAGO WILLMAN CALDERON PEREZ MD

Table of content: GEORGINA MEDINA DDS (NPI 1477320984)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790755759 NPI number — SANTIAGO WILLMAN CALDERON PEREZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CALDERON PEREZ
Provider First Name:
SANTIAGO
Provider Middle Name:
WILLMAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790755759
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/28/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4916 SAN MARINO CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE MARY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32746-2608
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-775-1175
Provider Business Mailing Address Fax Number:
321-256-1547

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
60 MEMORIAL MEDICAL PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALM COAST
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32164-5980
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-529-8953
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  ME 70874 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0200X , with the licence number: ME 70874 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000830802 . This is a "HUMANA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 13935 . This is a "FL MEMORIAL HEALTH NETWOR" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 150170 . This is a "HEALTHEASE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 251036700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 440001648 . This is a "RR MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 31616 . This is a "BC/BS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 100498000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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