Provider Demographics
NPI:1548609126
Name:LOPEZ, SANTIAGO (MD)
Entity Type:Individual
Prefix:
First Name:SANTIAGO
Middle Name:
Last Name:LOPEZ
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 1:353 E 17TH ST FL 2
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-3821
Mailing Address - Country:US
Mailing Address - Phone:212-420-3743
Mailing Address - Fax:
Practice Address - Street 1:353 E 17TH ST FL 2
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-3821
Practice Address - Country:US
Practice Address - Phone:212-420-3743
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-17
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY266247207Q00000X, 207QG0300X, 207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine