MEDICARE: DR. ERNESTO SANTISTEVAN PH.D.

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	103TC0700X	Clinical Psychologist	688	NM
2	103TP0016X	Prescribing (Medical) Psychologist	688	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114137684
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ERNESTO SANTISTEVAN PH.D.

Provider Business Mailing Address
First Line	:	3201 ZAFARANO DR STE C
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87507-2672
Country	:	US
Telephone Number	:	505-577-2607
Fax Number	:	505-982-1096

Provider Business Practice Location Address
First Line	:	4001 OFFICE COURT DR STE 1008
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87507-4929
Country	:	US
Telephone Number	:	505-577-2607
Fax Number	:	505-982-1096

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

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	03/18/2026

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