Provider Demographics
NPI:1154069557
Name:SANTIAGO, JORDAN ARMANDO
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:ARMANDO
Last Name:SANTIAGO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 HARRISON AVE # 2-341
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2821
Mailing Address - Country:US
Mailing Address - Phone:203-376-0469
Mailing Address - Fax:
Practice Address - Street 1:800 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1552
Practice Address - Country:US
Practice Address - Phone:617-636-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-25
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MA293160207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program