Healthcare Provider Details

I. General information

NPI: 1124089313
Provider Name (Legal Business Name): CAMILO SANTIAGO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: CAMILO S RIVERA

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 02/16/2023
Certification Date: 02/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 W UNIVERSITY AVE
MUNCIE IN
47303-3428
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 765-289-6381
  • Fax: 765-448-7646
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0101237102
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number47614
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number01081449A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: