Provider Demographics
NPI:1598826091
Name:SANTOS, ANTONIO M (PHD)
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:M
Last Name:SANTOS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:ANTONIO
Other - Middle Name:MONTEIRO
Other - Last Name:DOS SANTOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8950 VILLA LA JOLLA DR STE C230
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1712
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8950 VILLA LA JOLLA DR STE C230
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1712
Practice Address - Country:US
Practice Address - Phone:925-282-1778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19989103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CP19989AMedicare ID - Type Unspecified