Healthcare Provider Details

I. General information

NPI: 1811563547
Provider Name (Legal Business Name): ALBERTO MAXIMINO LLANEZA SANTACRUZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2021
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2031 BELMONT AVE
YOUNGSTOWN OH
44505-2401
US

IV. Provider business mailing address

2031 BELMONT AVE
YOUNGSTOWN OH
44505-2401
US

V. Phone/Fax

Practice location:
  • Phone: 330-480-3605
  • Fax: 330-480-2948
Mailing address:
  • Phone: 330-480-3605
  • Fax: 330-480-2948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number70951
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number57.251351
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: