Basic Information
| Provider Information | |||||||||
| NPI: | 1568446672 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANTIBANEZ | ||||||||
| FirstName: | JORGE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SANTIBANEZ -BANDALA | ||||||||
| OtherFirstName: | JORGE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 3299 | ||||||||
| Address2: | |||||||||
| City: | CARSON CITY | ||||||||
| State: | NV | ||||||||
| PostalCode: | 897023299 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7752220044 | ||||||||
| FaxNumber: | 8887000187 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 MEDICAL PKWY | ||||||||
| Address2: | |||||||||
| City: | CARSON CITY | ||||||||
| State: | NV | ||||||||
| PostalCode: | 897034625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7754458795 | ||||||||
| FaxNumber: | 7754455175 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2005 | ||||||||
| LastUpdateDate: | 05/30/2017 | ||||||||
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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 | 207R00000X | MD24602 | OR | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 13739 | NV | N | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | 7746287-1205 | UT | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 227344 | 05 | OR | MEDICAID |