Healthcare Provider Details

I. General information

NPI: 1023057577
Provider Name (Legal Business Name): POLLY A RUIZ SANTIAGO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 03/07/2023
Certification Date: 04/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 URB CATALANA
BARCELONETA PR
00617-2774
US

IV. Provider business mailing address

20 URBANIZACION CATALANA
BARCELONETA PR
00617
US

V. Phone/Fax

Practice location:
  • Phone: 787-846-5553
  • Fax: 787-854-5543
Mailing address:
  • Phone: 787-846-5553
  • Fax: 787-854-5553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number14036
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number14036
License Number StatePR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier14036
Identifier TypeOTHER
Identifier StatePR
Identifier IssuerLICENSE
# 2
IdentifierDM-14205-9
Identifier TypeOTHER
Identifier StatePR
Identifier IssuerASSMCA
# 3
IdentifierXR7587085
Identifier TypeOTHER
Identifier StatePR
Identifier IssuerSAMSA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: