Healthcare Provider Details

I. General information

NPI: 1063630259
Provider Name (Legal Business Name): LOURDES TERESA SANTIAGO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 11/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 S FORT HARRISON AVE BLDG C
CLEARWATER FL
33756-3301
US

IV. Provider business mailing address

PO BOX 1336
CLEARWATER FL
33757-1336
US

V. Phone/Fax

Practice location:
  • Phone: 727-483-9188
  • Fax: 727-412-8432
Mailing address:
  • Phone: 727-483-9188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberME97611
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: