Provider Demographics
NPI:1972993921
Name:ANGEL F. SAN ROMAN M.D., P.A.
Entity type:Organization
Organization Name:ANGEL F. SAN ROMAN M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGEL
Authorized Official - Middle Name:F
Authorized Official - Last Name:SAN ROMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-663-2845
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:33146-2436
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:33146-2436
Practice Address - Country:US
Practice Address - Phone:305-663-2845
Practice Address - Fax:305-663-9361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-29
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0055882208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL063497200Medicaid