Healthcare Provider Details

I. General information

NPI: 1114092822
Provider Name (Legal Business Name): SANTIAGO GANCAYCO DE LOS ANGELES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 01/30/2025
Certification Date: 01/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 SARNO RD
MELBOURNE FL
32935-3084
US

IV. Provider business mailing address

PO BOX 1137
MELBOURNE FL
32902-1137
US

V. Phone/Fax

Practice location:
  • Phone: 321-241-6800
  • Fax: 321-241-6888
Mailing address:
  • Phone: 321-952-9696
  • Fax: 321-952-7937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberME65644
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME65644
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: