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General NPI Number Information
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NPI Number | 1629389572
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Entity Type | Organization
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Legal Business Name | IVETTE SANTIAGO M D P A
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Dates
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Enumeration Date | 06/25/2010
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Last Update Date | 06/28/2010
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Provider Practice Location Address
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Address Line | 17521 US HIGHWAY 441 STE 15
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City | MOUNT DORA
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State | FL
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Zip | 32757-6737
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Country | US
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Telephone | 352-385-0123
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Fax | 352-383-3533
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Provider Business Mailing Address
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Address Line | 17521 US HIGHWAY 441 STE 15
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City | MOUNT DORA
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State | FL
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Zip | 32757-6737
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Country | US
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Telephone | 352-385-0123
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Fax | 352-383-3533
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. IVETTE SANTIAGO
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Credential | MD
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Telephone | 352-385-0123
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | ME65818
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License Number State | FL
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