Provider Demographics
NPI:1275795841
Name:SANTIAGO, IVAN (MD)
Entity Type:Individual
Prefix:DR
First Name:IVAN
Middle Name:
Last Name:SANTIAGO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-3909
Mailing Address - Country:US
Mailing Address - Phone:217-366-8107
Mailing Address - Fax:217-366-6106
Practice Address - Street 1:108 ROBINSON ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-8515
Practice Address - Country:US
Practice Address - Phone:217-442-8611
Practice Address - Fax:217-366-6106
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125049672208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation