Basic Information
| Provider Information | |||||||||
| NPI: | 1598976557 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUIZ CORDERO | ||||||||
| FirstName: | SANTOS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1485 37TH ST STE 102 | ||||||||
| Address2: | |||||||||
| City: | VERO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329606518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7725843114 | ||||||||
| FaxNumber: | 7725674340 | ||||||||
| Practice Location | |||||||||
| Address1: | 1485 37TH ST STE 102 | ||||||||
| Address2: | |||||||||
| City: | VERO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329606518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7258431147 | ||||||||
| FaxNumber: | 7725674340 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2007 | ||||||||
| LastUpdateDate: | 04/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311Z00000X | ACN501 | FL | N | Nursing & Custodial Care Facilities | Custodial Care Facility | 208D00000X | ACN501 | FL | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 107787600 | 05 | FL | MEDICAID |