Healthcare Provider Details

I. General information

NPI: 1932109196
Provider Name (Legal Business Name): MANUEL R CARRASCO-SANTIAGO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MANUEL R CARRASCO-SANTIAGO MD

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 12/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 W 11TH PL SUITE # 304
BIG SPRING TX
79720-4119
US

IV. Provider business mailing address

1501 W 11TH PL SUITE # 304
BIG SPRING TX
79720-4119
US

V. Phone/Fax

Practice location:
  • Phone: 432-714-4500
  • Fax: 432-714-4502
Mailing address:
  • Phone: 432-714-4500
  • Fax: 432-714-4502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License NumberJ5275
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberJ5275
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: