Basic Information
| Provider Information | |||||||||
| NPI: | 1578552303 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANTOS | ||||||||
| FirstName: | TERESA | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1636 S OCEAN DR | ||||||||
| Address2: | |||||||||
| City: | FT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333163244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9546145520 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9611 W BROWARD BLVD | ||||||||
| Address2: | |||||||||
| City: | PLANTATION | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333242334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544247000 | ||||||||
| FaxNumber: | 9544246003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2005 | ||||||||
| LastUpdateDate: | 08/31/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME56353 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 373798500 | 05 | FL | MEDICAID |