MEDICARE: MANUEL ANTONIO SANTIAGO RODRIGUEZ II

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	11384	PR

General Provider Information

NPI Number	:	1063412864
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MANUEL ANTONIO SANTIAGO RODRIGUEZ II

Provider Business Mailing Address
First Line	:	PO BOX 3425
Second Line	:
City	:	MAYAGUEZ
State	:	PR
Zip	:	00681-3425
Country	:	US
Telephone Number	:	787-826-2597
Fax Number	:	787-826-0491

Provider Business Practice Location Address
First Line	:	CALLE 65 DE INFANTERRIA #48,
Second Line	:	APARTADO 213
City	:	ANASCO
State	:	PR
Zip	:	00610
Country	:	US
Telephone Number	:	787-826-2597
Fax Number	:	787-826-0491

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/22/2005
Last Update Date	:	03/29/2012

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