Healthcare Provider Details

I. General information

NPI: 1669476552
Provider Name (Legal Business Name): SAMUEL SANTELICES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 06/18/2025
Certification Date: 06/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1859 SW NEWLAND WAY
LAKE CITY FL
32025-6966
US

IV. Provider business mailing address

1859 SW NEWLAND WAY
LAKE CITY FL
32025-6966
US

V. Phone/Fax

Practice location:
  • Phone: 386-758-0003
  • Fax: 386-755-7940
Mailing address:
  • Phone: 386-758-0003
  • Fax: 386-755-7940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME87551
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: