Healthcare Provider Details

I. General information

NPI: 1740032812
Provider Name (Legal Business Name): AMAURY SAMUEL SANTIAGO MALAVE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2024
Last Update Date: 04/03/2024
Certification Date: 03/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 CENTER DR
GAINESVILLE FL
32610-3007
US

IV. Provider business mailing address

4436 ARUBA BLVD
CLERMONT FL
34711-5251
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-6312
  • Fax:
Mailing address:
  • Phone: 787-365-8676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: