Healthcare Provider Details

I. General information

NPI: 1649478520
Provider Name (Legal Business Name): MARITZA SANTIAGO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

388 ZONA IND REPARADA 2 ANA D. PEREZ MARCHAND
PONCE PR
00716-2347
US

IV. Provider business mailing address

260 PASEO DEL PUERTO VISTA BAHIA
PENUELAS PR
00624-9776
US

V. Phone/Fax

Practice location:
  • Phone: 787-840-2575
  • Fax:
Mailing address:
  • Phone: 787-836-4770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number14282
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: