Basic Information
| Provider Information | |||||||||
| NPI: | 1730673666 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANTIAGO BETANCOURT | ||||||||
| FirstName: | NANNETTE | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1357 | ||||||||
| Address2: | |||||||||
| City: | CAGUAS | ||||||||
| State: | PR | ||||||||
| PostalCode: | 007261357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7872862800 | ||||||||
| FaxNumber: | 7872862805 | ||||||||
| Practice Location | |||||||||
| Address1: | 3 MUNOZ RIVERA | ||||||||
| Address2: | |||||||||
| City: | CAGUAS | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7872862800 | ||||||||
| FaxNumber: | 7872862805 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2018 | ||||||||
| LastUpdateDate: | 06/07/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 19946 | PR | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 19946 | 01 | PR | MEDICAL LICENSE | OTHER |