Provider Demographics
NPI:1487082707
Name:SANTOS, DOMINGO A
Entity type:Individual
Prefix:
First Name:DOMINGO
Middle Name:A
Last Name:SANTOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6164 GRAND CYPRESS CIR
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33463-7355
Mailing Address - Country:US
Mailing Address - Phone:561-385-9102
Mailing Address - Fax:
Practice Address - Street 1:6164 GRAND CYPRESS CIR
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33463-7355
Practice Address - Country:US
Practice Address - Phone:561-385-9102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-23
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLS532-161-63-460-0171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator