Basic Information
| Provider Information | |||||||||
| NPI: | 1588609002 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANTOS | ||||||||
| FirstName: | JOAQUIN | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8035 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672080035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166899135 | ||||||||
| FaxNumber: | 3166899102 | ||||||||
| Practice Location | |||||||||
| Address1: | 818 N CARRIAGE PKWY | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672084511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166512252 | ||||||||
| FaxNumber: | 3166512314 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2006 | ||||||||
| LastUpdateDate: | 07/13/2007 | ||||||||
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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 | 20499 | KS | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100001 | 01 | KS | HPK | OTHER | 11084871 | 01 | KS | MULTIPLAN | OTHER | 4418 | 01 | KS | PHS | OTHER | 17017 | 01 | KS | COVENTRY | OTHER | 0599906 | 01 | KS | BCBS | OTHER |