Healthcare Provider Details

I. General information

NPI: 1063412864
Provider Name (Legal Business Name): MANUEL ANTONIO SANTIAGO RODRIGUEZ II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 03/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE 65 DE INFANTERRIA #48, APARTADO 213
ANASCO PR
00610
US

IV. Provider business mailing address

PO BOX 3425
MAYAGUEZ PR
00681-3425
US

V. Phone/Fax

Practice location:
  • Phone: 787-826-2597
  • Fax: 787-826-0491
Mailing address:
  • Phone: 787-826-2597
  • Fax: 787-826-0491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number11384
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: