MEDICARE: MR. ANGEL F SAN ROMAN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	ME55882	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104803584
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ANGEL F SAN ROMAN MD

Provider Business Mailing Address
First Line	:	5965 PONCE DE LEON BLVD
Second Line	:	SUITE 2
City	:	CORAL GABLES
State	:	FL
Zip	:	33146-2423
Country	:	US
Telephone Number	:	305-663-2845
Fax Number	:	305-663-9361

Provider Business Practice Location Address
First Line	:	5965 PONCE DE LEON BLVD
Second Line	:	SUITE 2
City	:	CORAL GABLES
State	:	FL
Zip	:	33146-2423
Country	:	US
Telephone Number	:	305-663-2845
Fax Number	:	305-663-9361

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/28/2005
Last Update Date	:	08/23/2016

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