=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124214218
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA GUTIERREZ SANTIAGO M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2007
-----------------------------------------------------
Last Update Date | 10/27/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1601 PARK CENTER DR STE 6B
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32835-5700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-249-1234
-----------------------------------------------------
Fax | 407-249-1755
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1651 N SEMORAN BLVD
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32807-3575
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-249-1234
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 11742 I
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 17851
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | ME112748
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------