Basic Information
| Provider Information | |||||||||
| NPI: | 1932358009 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LABAULT-SANTIAGO | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | RAFAEL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5700 LAKE WORTH RD | ||||||||
| Address2: | STE 204 | ||||||||
| City: | GREENACRES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334634727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5619667707 | ||||||||
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| Practice Location | |||||||||
| Address1: | 140 JFK DR | ||||||||
| Address2: | |||||||||
| City: | ATLANTIS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334626608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5619686767 | ||||||||
| FaxNumber: | 5616410814 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2008 | ||||||||
| LastUpdateDate: | 02/27/2015 | ||||||||
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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 | 2084N0400X | P3375 | TX | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 14W87 | 01 | FL | BCBS | OTHER |