Provider Demographics
NPI:1063412864
Name:SANTIAGO RODRIGUEZ, MANUEL ANTONIO II
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:ANTONIO
Last Name:SANTIAGO RODRIGUEZ
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3425
Mailing Address - Street 2:
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00681-3425
Mailing Address - Country:US
Mailing Address - Phone:787-826-2597
Mailing Address - Fax:787-826-0491
Practice Address - Street 1:CALLE 65 DE INFANTERRIA #48,
Practice Address - Street 2:APARTADO 213
Practice Address - City:ANASCO
Practice Address - State:PR
Practice Address - Zip Code:00610
Practice Address - Country:US
Practice Address - Phone:787-826-2597
Practice Address - Fax:787-826-0491
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-22
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11384208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRG37245Medicare UPIN
PR0088089Medicare ID - Type Unspecified