Healthcare Provider Details

I. General information

NPI: 1700840741
Provider Name (Legal Business Name): LYNETTE MARLA SANTIAGO D.P.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 07/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

665 NEWTOWN RD
VIRGINIA BEACH VA
23462-1683
US

IV. Provider business mailing address

6477 COLLEGE PARK SQ STE 108
VIRGINIA BEACH VA
23464-3611
US

V. Phone/Fax

Practice location:
  • Phone: 757-490-1226
  • Fax:
Mailing address:
  • Phone: 757-222-4991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number0103300943
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: