Provider Demographics
NPI:1184866675
Name:SANTIAGO LAGO, IRMA MARIANA (MD)
Entity Type:Individual
Prefix:
First Name:IRMA
Middle Name:MARIANA
Last Name:SANTIAGO LAGO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:IRMA
Other - Middle Name:MARIANA
Other - Last Name:SANTIAGO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:102 POMONA DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-1616
Mailing Address - Country:US
Mailing Address - Phone:336-299-0000
Mailing Address - Fax:336-299-2335
Practice Address - Street 1:102 POMONA DR
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407
Practice Address - Country:US
Practice Address - Phone:336-299-0000
Practice Address - Fax:336-299-2335
Is Sole Proprietor?:No
Enumeration Date:2009-03-30
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2012-0350207Q00000X
NC2018-00102207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM85784842Medicaid
NMA102941OtherMEDICARE PTAN