Healthcare Provider Details

I. General information

NPI: 1699137877
Provider Name (Legal Business Name): KEVIN SANTOS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2016
Last Update Date: 06/25/2021
Certification Date: 06/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROSPECT AVE
HACKENSACK NJ
07601-1915
US

IV. Provider business mailing address

515 W 36TH ST APT 32B
NEW YORK NY
10018-0705
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-2419
  • Fax:
Mailing address:
  • Phone: 908-217-5234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number25MA10871200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: