Basic Information
| Provider Information | |||||||||
| NPI: | 1013103332 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANTOS | ||||||||
| FirstName: | CHARITO | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SANTOS | ||||||||
| OtherFirstName: | CHARITO | ||||||||
| OtherMiddleName: | B | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 13819 HANSON BLVD NW | ||||||||
| Address2: | |||||||||
| City: | ANDOVER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553047608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7633924001 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 13819 HANSON BLVD NW | ||||||||
| Address2: | |||||||||
| City: | ANDOVER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553047608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7633924001 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2007 | ||||||||
| LastUpdateDate: | 12/01/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 54594 | WI | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | MT189896 | PA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 54594 | WI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 58448 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1013103332 | 05 | WI | MEDICAID |