MEDICARE: IVETTE SANTIAGO M D P A

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	ME65818	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1316966708	OTHER	FL	INDIVIDUAL PROVIDER NPI

General Provider Information

NPI Number	:	1629389572
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IVETTE SANTIAGO M D P A

Provider Business Mailing Address
First Line	:	17521 US HIGHWAY 441 STE 15
Second Line	:
City	:	MOUNT DORA
State	:	FL
Zip	:	32757-6737
Country	:	US
Telephone Number	:	352-385-0123
Fax Number	:	352-383-3533

Provider Business Practice Location Address
First Line	:	17521 US HIGHWAY 441 STE 15
Second Line	:
City	:	MOUNT DORA
State	:	FL
Zip	:	32757-6737
Country	:	US
Telephone Number	:	352-385-0123
Fax Number	:	352-383-3533

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. IVETTE SANTIAGO
Credential	:	MD
Telephone Number	:	352-385-0123

Provider Enumeration Date	:	06/25/2010
Last Update Date	:	06/28/2010

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Directions to “IVETTE SANTIAGO M D P A ” Practice Location

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