Basic Information
| Provider Information | |||||||||
| NPI: | 1700912417 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANTIAGO GONZALEZ | ||||||||
| FirstName: | CARLOS | ||||||||
| MiddleName: | YAMIL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12171 SW 268TH ST | ||||||||
| Address2: | |||||||||
| City: | HOMESTEAD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330328001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052780200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2600 INDUSTRIAL PARK DR STE C | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338017135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636666100 | ||||||||
| FaxNumber: | 8632484395 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2007 | ||||||||
| LastUpdateDate: | 02/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 15313 | PR | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 15313 | 01 | PR | LICENSE | OTHER |