Basic Information
| Provider Information | |||||||||
| NPI: | 1336136696 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORALES | ||||||||
| FirstName: | SANTIAGO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20525 AMBERFIELD DR, STE 104 | ||||||||
| Address2: | |||||||||
| City: | LAND O'LAKES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8135367285 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 34650 US HIGHWAY 19 N STE 104 | ||||||||
| Address2: | |||||||||
| City: | PALM HARBOR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7272334895 | ||||||||
| FaxNumber: | 7274004712 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2005 | ||||||||
| LastUpdateDate: | 03/03/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0505X | ME64207 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1487907 | 01 | FL | WELLCARE | OTHER | P300829 | 01 | FL | FREEDOM | OTHER | 1008050 | 01 | FL | CAREPLUS | OTHER | P200489 | 01 | FL | OPTIMUM | OTHER | 023403000 | 05 | FL | MEDICAID | P01828223 | 01 | FL | SIMPLY | OTHER |