Healthcare Provider Details

I. General information

NPI: 1104849025
Provider Name (Legal Business Name): RICHARD SANTOS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 02/24/2021
Certification Date: 02/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E MICHIGAN AVE STE 102
JACKSON MI
49201-1406
US

IV. Provider business mailing address

100 E MICHIGAN AVE STE 102
JACKSON MI
49201-1406
US

V. Phone/Fax

Practice location:
  • Phone: 517-205-1731
  • Fax: 314-362-9878
Mailing address:
  • Phone: 517-205-1731
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301112253
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: