Provider Demographics
NPI:1194758292
Name:SUBAUSTE, JOSE SANTIAGO (MD)
Entity type:Individual
Prefix:DR
First Name:JOSE
Middle Name:SANTIAGO
Last Name:SUBAUSTE
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Gender:M
Credentials:MD
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Mailing Address - Street 1:1500 E WOODROW WILSON AVE
Mailing Address - Street 2:R&E BUILDING (151) - VAMC
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-5116
Mailing Address - Country:US
Mailing Address - Phone:601-362-4471
Mailing Address - Fax:601-364-1390
Practice Address - Street 1:1500 E WOODROW WILSON AVE
Practice Address - Street 2:R&E BUILDING (151) - VAMC
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-5116
Practice Address - Country:US
Practice Address - Phone:601-362-4471
Practice Address - Fax:601-364-1390
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2012-06-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MS16940207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS512I110033OtherPTAN
MS00122769Medicaid
MS302I467194Medicare PIN