Provider Demographics
NPI:1134163892
Name:MIRANDA SANTIAGO, ROBERTO ANTONIO (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERTO
Middle Name:ANTONIO
Last Name:MIRANDA SANTIAGO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 603898
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3898
Mailing Address - Country:US
Mailing Address - Phone:843-792-6200
Mailing Address - Fax:
Practice Address - Street 1:2501 S VANCE DR STE A
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29505-6163
Practice Address - Country:US
Practice Address - Phone:843-679-4019
Practice Address - Fax:843-679-4022
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC37361207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC373615Medicaid
PR0022980Medicare PIN
SCSC4606Medicare PIN