1881845782 NPI number — DR. SANTIAGO ELI MEDINA

Table of content: DR. SANTIAGO ELI MEDINA (NPI 1881845782)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881845782 NPI number — DR. SANTIAGO ELI MEDINA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEDINA
Provider First Name:
SANTIAGO
Provider Middle Name:
ELI
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
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:
1881845782
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/15/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
LE93 VIA PARIS
Provider Second Line Business Mailing Address:
L ANTIGUA
Provider Business Mailing Address City Name:
TRUJILLO ALTO
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00976-5414
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-585-4917
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
CARR 844 KM 4.2
Provider Second Line Business Practice Location Address:
CUPEY BAJO
Provider Business Practice Location Address City Name:
SAN JUAN
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00926
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-760-0770
Provider Business Practice Location Address Fax Number:
787-998-4415
Provider Enumeration Date:
10/09/2008

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: 208D00000X , with the licence number:  17361 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 17361 . This is a "STATE LICENSE" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".




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