Basic Information
| Provider Information | |||||||||
| NPI: | 1306813845 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LARDIZABAL | ||||||||
| FirstName: | SANTIAGO | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7640 | ||||||||
| Address2: | |||||||||
| City: | SURPRISE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235849985 | ||||||||
| FaxNumber: | 6235849986 | ||||||||
| Practice Location | |||||||||
| Address1: | 19424 N RH JOHNSON BLVD | ||||||||
| Address2: | |||||||||
| City: | SUN CITY WEST | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235849985 | ||||||||
| FaxNumber: | 6235849986 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2006 | ||||||||
| LastUpdateDate: | 03/02/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 14445 | AZ | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 239427 | 05 | AZ | MEDICAID |