Provider Demographics
NPI:1003003856
Name:SANTIAGO, CYNTHIA (MD)
Entity Type:Individual
Prefix:DR
First Name:CYNTHIA
Middle Name:
Last Name:SANTIAGO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-2568
Mailing Address - Country:US
Mailing Address - Phone:631-732-6984
Mailing Address - Fax:631-732-7019
Practice Address - Street 1:5 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-3336
Practice Address - Country:US
Practice Address - Phone:631-732-6984
Practice Address - Fax:631-732-7019
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-26
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY217808207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02162494Medicaid
NY02162494Medicaid
NYH37637Medicare UPIN