Provider Demographics
NPI:1174565162
Name:SANTILLANES, MICHAEL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:SANTILLANES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MARIO
Other - Middle Name:
Other - Last Name:SANTILLANES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:5755 BIRCHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92509-7331
Mailing Address - Country:US
Mailing Address - Phone:714-717-8285
Mailing Address - Fax:
Practice Address - Street 1:115 W E ST
Practice Address - Street 2:
Practice Address - City:TEHACHAPI
Practice Address - State:CA
Practice Address - Zip Code:93561-1607
Practice Address - Country:US
Practice Address - Phone:714-717-8285
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA77181207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH76721Medicare UPIN