Healthcare Provider Details

I. General information

NPI: 1780919209
Provider Name (Legal Business Name): DAVID SANTIAGO JR. L.M.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2009
Last Update Date: 10/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6821 W HILLSBOROUGH AVE SUITE 18
TAMPA FL
33634-5003
US

IV. Provider business mailing address

2286 CEDAR TRACE CIR
TAMPA FL
33613-2586
US

V. Phone/Fax

Practice location:
  • Phone: 813-443-4593
  • Fax: 813-443-4595
Mailing address:
  • Phone: 813-480-8113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License NumberMA57107
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: