Healthcare Provider Details

I. General information

NPI: 1265821094
Provider Name (Legal Business Name): LOURDES T SANTIAGO M.D.P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2015
Last Update Date: 01/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberME97611
License Number StateFL

VIII. Authorized Official

Name: DR. LOURDES SANTIAGO
Title or Position: SURGEON
Credential:
Phone: 727-483-9188