Provider Demographics
NPI:1104803584
Name:SAN ROMAN, ANGEL F (MD)
Entity type:Individual
Prefix:MR
First Name:ANGEL
Middle Name:F
Last Name:SAN ROMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5965 PONCE DE LEON BLVD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33146-2423
Mailing Address - Country:US
Mailing Address - Phone:305-663-2845
Mailing Address - Fax:305-663-9361
Practice Address - Street 1:5965 PONCE DE LEON BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33146-2423
Practice Address - Country:US
Practice Address - Phone:305-663-2845
Practice Address - Fax:305-663-9361
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-28
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME55882208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL063497200Medicaid
FL10771Medicare ID - Type Unspecified
E59052Medicare UPIN