=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942312103
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIBEL COLON-SANTIAGO M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2006
-----------------------------------------------------
Last Update Date | 10/27/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1515 NE LAWRIE TATUM RD
-----------------------------------------------------
City | LAWTON
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73507-3002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-354-5270
-----------------------------------------------------
Fax | 580-354-5289
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2112 NW 55TH ST
-----------------------------------------------------
City | LAWTON
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73505-3118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-248-0972
-----------------------------------------------------
Fax | 580-248-0972
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 10773
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------