Healthcare Provider Details

I. General information

NPI: 1053377820
Provider Name (Legal Business Name): SANTIAGO VERA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 NONCONNAH BLVD SUITE 120
MEMPHIS TN
38132-2113
US

IV. Provider business mailing address

66 N PAULINE ST SUITE 206
MEMPHIS TN
38105-5105
US

V. Phone/Fax

Practice location:
  • Phone: 901-448-2300
  • Fax: 901-448-6657
Mailing address:
  • Phone: 901-448-7642
  • Fax: 901-448-8015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number11761
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: