Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208D00000X | General Practice Physician | 14036 | PR |
NPI | 1023057577 |
---|---|
Provider Name | Dr. Polly A Ruiz Santiago |
First Address | Barceloneta, PR 00617 |
Second Address | Barceloneta, PR 00617-2774 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/06/2006 |
Last Update Date | 22/04/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
14036 | LICENSE (01) | PR |
BR7587085 | DEA (01) | PR |
DM-14205-9 | ASSMCA (01) | PR |
XR7587085 | SAMSA (01) | PR |