Provider Demographics
NPI:1679538664
Name:SANTA ROSA DE LIMA MEDICAL PA
Entity type:Organization
Organization Name:SANTA ROSA DE LIMA MEDICAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SANTIAGO
Authorized Official - Middle Name:W
Authorized Official - Last Name:CALDERON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-268-5415
Mailing Address - Street 1:4916 SAN MARINO CIR
Mailing Address - Street 2:C/O S. CALDERON, MD
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-2608
Mailing Address - Country:US
Mailing Address - Phone:407-268-5415
Mailing Address - Fax:
Practice Address - Street 1:1055 SAXON BLVD
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8468
Practice Address - Country:US
Practice Address - Phone:407-268-5415
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-20
Last Update Date:2008-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME70874174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL150170OtherHEALTHEASE
FL94709OtherBC/BS
FL000830802OtherHUMANA
FL13935OtherFL MEMORIAL HEALTH NETWOR
FL263393100Medicaid
FLCH6285OtherRR MEDICARE
FL150170OtherHEALTHEASE
FLF74830Medicare UPIN