Provider Demographics
NPI:1114993896
Name:SANTIAGO-MALDONADO, IDA MARY (MD)
Entity Type:Individual
Prefix:DR
First Name:IDA
Middle Name:MARY
Last Name:SANTIAGO-MALDONADO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:IDA
Other - Middle Name:MARY
Other - Last Name:S-M-LOPEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2817 REILLY ROAD MCXC-COD CREDENTIALS
Mailing Address - Street 2:WOMACK ARMY MEDICAL CENTER
Mailing Address - City:FORT BRAGG
Mailing Address - State:NC
Mailing Address - Zip Code:28310
Mailing Address - Country:US
Mailing Address - Phone:910-907-8922
Mailing Address - Fax:910-907-6069
Practice Address - Street 1:2817 REILLY ROAD MCXC-COD CREDENTIALS
Practice Address - Street 2:WOMACK ARMY MEDICAL CENTER
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28310
Practice Address - Country:US
Practice Address - Phone:910-907-8922
Practice Address - Fax:910-907-6069
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101058066207R00000X
VA207UN0902X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & Therapy