Provider Demographics
NPI:1932263563
Name:SANTIAGO, EDGARDO LUIS (MD)
Entity type:Individual
Prefix:DR
First Name:EDGARDO
Middle Name:LUIS
Last Name:SANTIAGO
Suffix:
Gender:M
Credentials:MD
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 1876
Mailing Address - Street 2:
Mailing Address - City:CIDRA
Mailing Address - State:PR
Mailing Address - Zip Code:00739-1876
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CARR 172 KM 6.1 SECTOR LA SIERRA
Practice Address - Street 2:BO.CANABONCITO
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725
Practice Address - Country:US
Practice Address - Phone:787-745-6113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR14881208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRH99281Medicare UPIN