Healthcare Provider Details

I. General information

NPI: 1689673774
Provider Name (Legal Business Name): DOMINGO BETANCES SANTOS M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 02/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 CARR 891 BO. PUEBLO
COROZAL PR
00783-1977
US

IV. Provider business mailing address

PO BOX 1838
COROZAL PR
00783-7003
US

V. Phone/Fax

Practice location:
  • Phone: 787-859-0403
  • Fax: 787-802-1222
Mailing address:
  • Phone: 787-859-0403
  • Fax: 787-802-1222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number8192
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: