Basic Information
| Provider Information | |||||||||
| NPI: | 1922337211 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DE LOS SANTOS FLORIAN | ||||||||
| FirstName: | ROOSEVELT | ||||||||
| MiddleName: | ANTONIO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 S PINE ISLAND RD STE 800 | ||||||||
| Address2: | |||||||||
| City: | PLANTATION | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333243923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7862933200 | ||||||||
| FaxNumber: | 3052329082 | ||||||||
| Practice Location | |||||||||
| Address1: | 15077 S DIXIE HWY | ||||||||
| Address2: | |||||||||
| City: | PALMETTO BAY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331767930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7862933200 | ||||||||
| FaxNumber: | 3052329082 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2009 | ||||||||
| LastUpdateDate: | 05/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083C0008X | ME106015 | FL | N | 208000000X | ME106015 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 001892200 | 05 | FL | MEDICAID |