Provider Demographics
NPI:1306156104
Name:GREGORIO S SANTOS MD PA
Entity type:Organization
Organization Name:GREGORIO S SANTOS MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORIO
Authorized Official - Middle Name:S
Authorized Official - Last Name:SANTOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-521-9467
Mailing Address - Street 1:6125 54TH AVE N STE B
Mailing Address - Street 2:
Mailing Address - City:KENNETH CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33709-1830
Mailing Address - Country:US
Mailing Address - Phone:727-521-9467
Mailing Address - Fax:727-521-0416
Practice Address - Street 1:6125 54TH AVE N STE B
Practice Address - Street 2:
Practice Address - City:KENNETH CITY
Practice Address - State:FL
Practice Address - Zip Code:33709-1830
Practice Address - Country:US
Practice Address - Phone:727-521-9467
Practice Address - Fax:727-521-0416
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-14
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0072417261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL21062Medicare PIN
FLG63232Medicare UPIN